The Health of Older People: A Social Survey [Reprint 2014 ed.] 9780674421646, 9780674428232

Citation preview

THE

HEALTH OF

OLDER PEOPLE

THE

HEALTH OF

OLDER PEOPLE A Social Survey

ETHEL SHANAS

HARVARD UNIVERSITY PRESS Cambridge, Massachusetts · 1962

© 1962 by the President and Fellows of Harvard College All rights reserved Distributed in Great Britain by Oxford University Press, London Library of Congress Catalog Card Number: 62-17225 Printed in the United States of America

PREFACE This book is a summary of the findings of a 1957 survey of the health needs of older people, as reported by a nationwide sample of persons sixty-five years of age and older and by those to whom older people would turn in a health crisis. I have drawn certain conclusions from these findings. Detailed tabulations have been included in the manuscript, however, to enable the reader to make his own judgments and interpretations of the data. The limitations of the data are described in the text and in the technical appendices. Because this volume is primarily a summary report, only minimal references are made to the literature dealing with older people. In recent years there has been an increasing number of publications about the social and psychological aspects of the life of the elderly. Much of this material is highly speculative. Illustrative case histories, however interesting to read, and so-called objective reports in which unwarranted interpretations and forecasts are made from limited statistical data are not adequate evidence on which to base conclusions about older people. On the other hand, one can also find in the literature a growing body of knowledge about the aged in the United States and a variety of thoughtful hypotheses for further investigation. I believe that the present report makes a contribution to our knowledge about older people in this country. Further, I should like to see some of the hypotheses that I have developed studied critically by other investigators. This survey was a research project of the National Opinion Research Center of the University of Chicago, financed by a grant from the Health Information Foundation. The directors of the Foundation, in allocating funds for this project in 1956, demonstrated once again their awareness of the social and economic aspects of the health needs of the American people. George Bugbee, Foundation President, and Odin W. Anderson, Research Director, ν

Preface were most cooperative during the five years from survey planning to the finished report. Dr. Anderson also suggested certain of the content areas of the original questionnaires and was a thoughtful critic of the survey findings. Any national survey involves the concerted work of a great many people. Several hundred persons associated with the National Opinion Research Center had some part in making this report possible. I am particularly grateful to Clyde W. Hart, now Director Emeritus of the Center, for his guidance, suggestions, and encouragement. Peter H. Rossi, the present Director, was helpful while the report of the study was being written. No study can be better than its basic data. Several of my colleagues made major contributions to the design and planning phases of this survey. James S. Coleman, now of the Johns Hopkins University, served as sampling consultant. He was succeeded in this assignment by Jacob J. Feldman. Both Mr. Coleman and Mr. Feldman helped in the design of the original questionnaires. Mr. Feldman also read and criticized all publications based on this research, as well as all drafts of the present manuscript. Shirley A. Star, now of the Johns Hopkins University, critically reviewed the original questionnaires and the study design. Selma F. Monsky, now of the Government Social Survey, London, England, formerly Field Director of the National Opinion Research Center, helped in the design of the original questionnaires and trained and supervised the field staff in their use. As I review the completed questionnaires, I realize once again how much of the success of this survey was due to her efforts. Other National Opinion Research Center staff members who did special work on this project include Frederic J. Meier, and, later, Harold Levy, who were responsible for the mechanical processing of the data, and Sanford Abrams, Mary N. Adams, Annie O. Blair, Fansayde N. Calloway, Ada B. Caplow, Ursula Dibble, Mary Ann Kaufman, Clyde Pope, Nella V. Siefert, Esther G. Silverman, Marlene Simon, and Beatrice R. Treiman. The thousands of persons who were interviewed will probably never hear of this book, much less read it. Nevertheless, their cooperation made this report possible and I am indebted to all of them for giving us their time and telling us their experiences. January 1962

Ethel Shanas vi

CONTENTS Chapter I.

Introduction

1

Chapter II.

Reported Illness, the Use of "Medical Care, and Payments for Care Among Older People

6

Chapter III. Chapter IV. Chapter V. Chapter VI. Chapter VII. Chapter VIII. Chapter IX.

The Very Sick Among Older People Employment, Income, and Meeting the Costs of Medical Care The Living Arrangements of Older People Older People and Their Families The Health of Older People: The Reports of Responsible Individuals The Public Views the Needs of Older People Conclusions: The Older Person in the United States

Appendix A.

Definitions and Explanations

Appendix B.

Methodology, by Jacob J. Feldman and James S. Coleman Reports and Papers Based on the Survey Interview Questionnaires

Appendix C. Appendix D. Index

Vll

32 54 94 107 142 162 175 185 193 207 209 247

TABLES 1. Prevalence of selected types of illnesses per 1,000 older persons reporting some illness during the four weeks before their interviews 2. Comparison of NORC four-week illness prevalence data with data from other household surveys 3. Per cent of all older persons and per cent of such persons with impairments reporting restrictions on activities due to impairment and disability 4. Average number of physician visits per year 5. Percentage distribution of physician visits 6. Percentage distribution of time intervals since most recent physician visit 7. Number of reported hospital admissions in short-stay hospitals, number of hospital days, and average length of stay 8. Annual rates of hospitalization in general hospitals, number of admissions, average annual days 9. Use of hospitals annually, four national surveys, 1956-1958 10. Average length of stay in short-stay hospitals of older persons reporting hospitalization 11. Percentage distribution of length-of-stay intervals in short-stay hospitals 12. Number of appliances or special health helps 13. Per cent of older persons reporting use of specified appliances 14. Per cent of all older persons with expenditures for new appliance or for upkeep 15. Average amount per year spent on health appliances 16. Payments for physician services by older persons with out-ofhospital contacts with physicians 17. Use of hospitals reported in three national surveys, by hospital insurance coverage status 18. Mean gross in-patient hospital charges, two nationwide surveys 19. Per cent of older persons with stays in short-term hospitals reporting payments to physicians for in-patient hospital care 20. Mean net physicians' charges per older person and per older person incurring such charges 21. Mean net "other" medical charges per older person and per older person incurring such charges 22. Mean net medicine charges per older person and per older person incurring such charges

ix

8 9 11 12 13 14 16 16 17 19 19 21 21 22 23 24 25 26 27 27 28 28

Tables 23. Total net charges for physicians' care, "other" medical care, and medicine 24. Total net charges for physicians' care, "other" medical care, and medicine among older persons who incurred all three charges 25. Percentage of older persons in each category of the illness index 26. Characteristics of "very sick" in older population, comparing those interviewed and those "too sick" to be interviewed 27. Characteristics of very sick who were interviewed and of all other people 28. Percentage distribution of physician visits, very sick and all other older people 29. Percentage distribution of time intervals since last physician visit, very sick and all other older people 30. Percentage distribution of number of appliances or special health helps, very sick and all other older people 31. Percentage distribution of very sick and all other older people reporting use of specified appliances 32. Payments for physicians services among very sick and all other older persons with contacts with physicians 33. Mean net physicians' charges for very sick and all other older people, and per person incurring charges 34. Mean net "other" medical charges for very sick and all other older people, and per person incurring charges 35. Mean net medicine charges for very sick and all other older people, and per person incurring charges 36. Total net charges for physicians' care, "other" medical care, and medicine, and percentage spent for each 37. Self-assessment of health by very sick and other older people 38. Attitudes toward health and doctors of very sick and other older people 39. Employment status of persons 65 and over, and 60 to 64 40. Reasons for retirement 41. What retired people miss most about their jobs 42. Age at which people still in the labor force expect to retire 43. What employed people say they would miss most about their jobs 44. Money income and living arrangements of couples and unmarried persons 45. Noncash assistance and living arrangements of couples and unmarried persons reporting noncash assistance 46. Distribution of older persons by main source of money income 47. Income of couples and unmarried persons, by main source 48. Main source of income and noncash assistance reported by very sick and other older people 49. Assets available to pay $500 medical bill, couples and unmarried persons 50. Sources of funds to be used in payment of $500 medical bill 51. Voluntary health insurance status 52. Characteristics of voluntary health insurance coverage, currently insured persons 53. Characteristics of former voluntary health insurance coverage 54. Attitudes toward government health insurance, persons aged 65 years and over 55. Attitudes related to financial support, all older persons and those who favor government health insurance 56. How older people paid current doctor bills 57. How older people paid hospitals and physicians 58. Reasons for not seeing a doctor 59. Complaints about health care, very sick and all other older people X

29 30 35 37 39 40 42 43 44 46 46 47 48 48 50 51 55 57 58 60 61 64 66 67 69 70 74 76 78 79 80 82 83 84 86 87 88

Tables 60. Characteristics of older persons reporting unmet medical needs due to lack of money 61. Living arrangements of older persons with and without living children 62. Location of nearest child 63. Living arrangements of very sick and all other older persons 64. Preference in living arrangements 65. Preference in living arrangements, classified by presence of child in home 66. Evaluation of attitudes of adult children by older persons with and without children 67. Relationship of responsible individual to older respondent and proportion of each category of individuals interviewed 68. Reasons why responsible individuals named by older people were not interviewed 69. Age and sex of responsible individuals 70. Living arrangements of older people and health ratings as reported by responsible individuals 71. Location of nearest son or daughter of the very sick and all other older people who report living children 72. Location of nearest son or daughter of older people with living children, by health rating of the older person 73. Should mother join the family?—Answers of older persons, of responsible individuals, and of public cross-section 74. Should mother join the family?—Answers of older people and of those to whom they would turn in a health crisis 75. Maintenance of parent's home versus recreation—Answers of older persons and of responsible individuals 76. Maintenance of parent's home versus recreation—Answers of older people and of those to whom they would turn in a health crisis 77. Wife's shopping versus mother's visiting doctor—Answers of older persons, of responsible individuals, and public cross-section 78. Wife's shopping versus mother's visiting doctor—Answers of older people and of those to whom they would turn in a health crisis 79. Where to go on Easter Sunday—Answers of older persons, of responsible individuals, and of public cross-section 80. Where to go on Easter Sunday—Answers of older people and of those to whom they would turn in a health crisis 81. Who should take care of older people when they are no longer working?—Answers of older persons, of responsible individuals, and of public cross-section 82. Who should take care of older people when they are no longer working?—Answers of older people and of those to whom they would turn in a health crisis 83. Who should take financial responsibility for aged parent?—Answers of older persons, of responsible individuals, and of public cross-section 84. Who should take financial responsibility for aged parent?—Answers of older people and of those to whom they would turn in a health crisis 85. Parental support versus a car—Answers of older people and of responsible individuals 86. Parental support versus a car—Answers of older people and of those to whom they would turn in a health crisis 87. Assessment of health by older people and by those to whom they would turn in a health crisis 88. Time spent in bed because of illness during 12 months before the interview

xi

90 96 98 101 103 104 105 111 112 114 117 119 119 121 122 124 125 127 128 129 131 133 134 135 137 138 139 144 147

Tables 89. Who usually paid the physician bills of older people 90. How older people paid hospital charges 91. How older people who had serious illnesses in recent years paid the costs for the illness 92. Sources of funds older people would use to pay a $500 medical bill 93. Proportion of older people with unmet needs due to lack of money 94. Attitudes toward government health insurance—Reports of older people and those to whom they would turn in a health crisis 95. Family income and attitudes related to financial support of older people—Reports of all responsible individuals and those who favor government health insurance 96. Attitudes toward health and doctors—Reports of older people and of those to whom they would turn in a health crisis 97. The age at which men and women are considered old—Replies of public cross-section 98. Proportion of public cross-section with living parents 99. The health of aged parents—Evaluation of those in public crosssection with living parents 100. The health of older people—Evaluation of those in public crosssection 101. How do older persons usually pay their hospital bills?—Answers of those in public cross-section 102. Who should take care of older people when they are no longer working?—Answers of all those in public cross-section 103. Proportion of those in public cross-section with parents or parentsin-law now supporting or anticipating support of aged parents or parents-in-law 104. What should a person do while he's young to help support himself after he stops working?—Answers of those in public cross-section 105. Expected financial status at 65 of those in public cross-section aged 21 to 64 106. Present situation and expectation of joint households among those in public cross-section with living parents or parents-in-law 107. Preferences in living arrangements for older people of those in public cross-section 108. Disposition of cases actually located through the screening process and assigned for interview 109. Approximate addends and subtrahends for the establishment of 95-per-cent confidence limits 110. Comparison between the National Opinion Research Center OlderPerson survey estimates and the Census Current Population survey estimates 111. Comparison between the National Opinion Research Center public cross section estimates and the Census Current Population survey estimates

Xll

151 153 154 155 157 158 159 160 163 164 165 166 167 168 169 169 170 171 172 197 201 203 205

THE

HEALTH OF

OLDER PEOPLE

I Introduction This is a report of the findings of a 1957 survey of the health needs of older people. The survey was undertaken for two reasons: older people and their health needs were a matter of current concern, and further it was believed that the health needs of older people could be understood only in relation to their total life situation. While gross reports of the incidence of illness or of expenditures for medical care among the elderly are useful for some purposes, they still do not answer the questions of "How sick are older people in the United States?" or "What does it mean to be old and sick at the present time in this country?" It is to this kind of inquiry that the survey was directed, and some of the answers to these questions appear in the chapters that follow. Despite the present interest in the United States in older people, knowledge about many aspects of the life of the seventeen million Americans 65 and over is sparse and deficient. While the Federal Census Bureau and Social Security Administration supply certain basic information about older people, there are many areas in which no adequate information exists. To fill this void, images of older people have been created from the experience of specialists and of the general public. Since those older people whose needs are greatest are those most likely to come to public attention, it is the indigent, the sick, the lonely, and the isolated among the older population who have played the largest part in creating the image of the aged prevalent in the United States today. Much of what is presented to the public as "facts" about older people today are not facts,

1

The Health of Older People but impressions gained from small and selected groups in our older population. Recent Population Changes

The present-day concern with older people and their needs reflects, among other things, significant recent demographic or population changes. The number of persons 65 and over has increased markedly and rapidly. The ratio of men to women has shifted in this older age-group. The proportion of older men in the labor force has declined. The proportion of older people has increased among persons in the dependent ages (under 20 and over 65). Let us look briefly at each of these changes. Between 1900 and 1950 the population of the United States almost doubled, growing from some 76 million people to 151 million people. During this same half century, however, that part of the population aged 65 and over nearly quadrupled in size, increasing from about three to twelve million people or from about 4 per cent of the total population in 1900 to 8 per cent in 1950. By July 1, 1957, when the data for this volume were collected, the population of the United States had grown to 168 million, an increase of 11 per cent in the seven years since the 1950 Census, while the number of persons 65 and over had grown to about fifteen million, an increase of 20 per cent. The proportion of older people in the general population, however, had risen only slightly in the seven-year period, from 8.0 to 8.8 per cent. While the numbers of persons in the years past 65 have increased markedly in the last half-century, life expectancy for those reaching age 65 has increased very little, from 11.9 years in 1900 to 13.8 years in 1950. Once an individual had reached age 65 in the year 1900, on the average, he could have been expected to live almost as long as his counterpart would in 1950 or 1957. Of course, in 1900 only one person in twenty-five was 65 or older, while in 1957 one person in eleven was in this age-group. In 1900 three million persons were 65 and over, while in 1957 about fifteen million persons were in this age-group. If there are special needs associated with aging, on the basis of numbers alone these needs affected five times as many people in 1957 as they did in 1900. In the last half-century, the proportion of men and women in the older age-group has changed greatly. In 1900 there were 102 men 65 and over for every 100 women in this age-group; by 1950 there 2

Introduction were only 89 men for every 100 women 65 and over.1 By 1960, continuing this trend, there were 83 men for every 100 women in the older age-group.2 Most older men are married, while most older women are widowed. If current trends continue, a large increase in the number of aged widows can be foreseen in the very near future. The increase in the number of older people has occurred during a period of rapid technological advance in this country. Coincident with this technological progress there has been a marked decline in the proportion of older men who are employed. In 1900 three of every five men age 65 and over were in the labor force; by 1956 only two of every five men 65 and over were at work or seeking work.3 The introduction of new, more efficient methods of manufacturing, the decline in the proportion of persons engaged in agriculture, and the broadening of Social Security benefits all point to a continuation of this long-time trend. While in the near future there will be more men 65 and over in the United States than ever before, a smaller proportion of these men will be employed. The ratio of persons in the dependent ages (under 20 and over 65) to those aged 20 to 64 also reflects the increase in the number of old people. In 1900 there were 94 persons in the dependent population for every 100 persons in the years between 20 and 64, commonly thought of as the "working years." Only 8 of these 94 persons in the dependent ages were 65 and over; 86 were under 20. By 1950 the ratio of persons in the dependent years to those in the working years had dropped to 72 per 100; however, 14 of these 72 were 65 and over, while 58 were under 20. By 1960, the ratio of dependent persons to those in the working force was expected to be 88 per 100, a proportion approaching that reported for 1900. Now, however, 17 of these 88 were 65 years and over; 71 were under 20.4 The Health Needs of Older People

The research project reported in this volume had several objectives. One of these was to secure factual data about the life situation 1 Henry D. Sheldon, "Future Trends in Our Older Population," in W. Donahue and C. Tibbitts, The New Frontiers of Aging (Ann Arbor, University of Michigan Press, 1957), p. 72. 2 For 1960, see New Population Facts on Older Americans. A Staff Report to the Special Committee on Aging, United States Senate, May 24, 1961 (Washington, U. S. Government Printing Office, 1961). 8 By 1960, only one older man in three was still in the labor force. See New Population Facts on Older Americans, p. 2. 4 Sheldon, "Future Trends in Our Older Population," p. 74.

3

The Health of Older People of older people in this country, particularly about the use of medical care by the older population. The other objectives of the project were to secure answers to less obvious but equally important questions. These were: 1. What are the health needs of older people as they see them? 2. How and to what extent do children and other relatives assume responsibility—financial and other—for older people? 3. What do older people and the general American public think about family responsibility for the aged? This research project was not intended to determine the incidence of different kinds of illness among older people, nor to secure medically verified statements of what illnesses most affected the older population. Several studies of this type have been begun since 1957 or are now projected. Outstanding among these is the United States National Health Survey which began nationwide interviewing in July 1957, and which makes available a continuous inventory of the health of the American people. In this project the health situation of older people and their use of medical care facilities was investigated against the background of their living arrangements, their economic status, their family relationships, and their conceptions of their health status. Naturally, there are limitations to data about illness secured by the household interview technique used in this study. Some of those interviewed may be unaware of conditions they have which a physician would discover. Others may not know or recall enough to describe their conditions accurately or they may even forget completely about a past illness or physician's visit. Nevertheless, the household interview can supply much information that is not available from any other source—particularly information about health problems as the individual who is affected perceives them. The health of older people has ramifications which extend beyond the presence or absence of illness determined clinically, and it is on these social and economic implications that this study is focused. Design of this Study

The data reported in this volume were secured by a national survey. As the study was finally designed, it included five separate population groups. Two samples of the population of the United States, one comprised of persons aged 60 to 64 and the other of persons

4

Introduction aged 65 and over, were basic to the survey design. These two samples, area-probability samples of the general design employed by the United States Census Bureau for its current population survey, represented a cross-section of all Americans in the two age-groups studied. Further, each person in these two samples was asked to identify the family member, relative, or friend to whom he would turn in a health crisis, and these family members, relatives, and friends were also interviewed. The fifth group interviewed was a cross-section of the adult American public, who were questioned about family responsibility for older people. The methodology of the survey is explained fully in Appendix B. Primary attention is given in this report to the findings for persons aged 65 and over. A random cross-section of this older population was interviewed at length by the staff of the National Opinion Research Center in the spring of 1957. In all, 1,734 people 65 and over were interviewed—82.8 per cent of the 2,094 older people located by the survey screening technique in some 6,755 households. The survey omitted only one group among the older population: those in institutions. The number of older people in institutions has been estimated at between 450,000 and 750,000—or from 3 to 5 per cent of the older population. Aside from this group, the survey method insured full representations of all segments, however diverse, which made up America's more than fifteen million older people in 1957.

5

II Reported Illness, the Use of Medical Care, and Payments Most reports oil the health of older people put the seventeen million people aged 65 and over into a single category. In the survey reported here, however, the differences in physical well-being that might be expected in a group of people selected on the basis of age alone were very apparent. Some reported themselves as quite ill; others had no health complaints. Some were heavy users of medical care facilities; others had not seen a doctor for five years or more. There is marked value in reporting the findings for all older people as a single group because available information on health and medical care for the total older age-group is still quite limited. On the other hand, the variability among older persons both in their self-reports of illness and in their use of medical facilities suggests that a more meaningful analysis of the health needs of this agegroup would result if those persons who seemed to be the "sickest" were isolated and considered separately. Later in this report, therefore, comparisons are made of the health needs of various groups among persons categorized as "older people." This chapter summarizes the extent of illness and disability reported among all older persons in the United States living outside of institutions. It also gives the survey findings on their utilization of physicians' services, hospital care, home nursing care, and special health appliances, as well as the costs of their medical care. Some of these findings supplement existing reports; others provide new information about the older population.

6

Illness, Medical Care,

Payments

Prevalence of Illness

In answer to the question, "In the past four weeks, did anything —like sickness, or any old injury or any health problem, bother you? What was it?" half of all older people (50 per cent) named one or more illnesses. An additional third (34 per cent), although they said "No" to this question, reported one or more current illnesses when read a list of specific chronic conditions and symptoms. In all, then, seventeen of every twenty persons interviewed in this survey reported at least one recent illness.1 Almost equal proportions of men and women (82 and 85 per cent, respectively) said that they had been ill. The average number of illnesses reported was four per person. Table 1 gives the prevalence of illness among the older population by broad diagnostic categories. Half of all respondents said that they had suffered from diseases of the circulatory system during the four-week period; one third reported arthritis and rheumatism. Among ailments common to both sexes, men reported a substantially higher incidence of ear disorders and respiratory symptoms; women reported more hypertension, varicose veins, arthritis and rheumatism, constipation, and headaches. Respondents were also asked, "Is there anything else that bothers you about your health, even if it hasn't especially troubled you these last four weeks?" but replies to this question were not included in computing the prevalence rates shown in Table 1. The proportion of older people reporting illness was higher in this study than in previous household surveys with comparable sampling methods. The proportion was significantly higher in this study than in reports for the same age-group in the California health survey in 1954-55 and the 1952 survey of New York City made for the Health Insurance Plan of Greater New York.2 1

One person in every twenty-five older persons located in the general population could not be interviewed because he or the person taking care of him reported that he was "too sick." A full statement of the characteristics of the sample and the effect of the omission of the "too sick" and the institutionalized is given in Appendix B. 2 In the United States each recent household survey of illness has consistently secured higher rates for most diagnostic categories than the previous survey and significantly higher rates than those reported in household surveys some years ago. A discussion of this topic appears in Commission on Chronic Illness, Chronic Illness in the United States, Vol. IV: Chronic Illness in a Large City, the Baltimore Study (Cambridge, Mass., Harvard University Press, 1957), pp. 498—499.

7

The Health of Older

People

T A B L E 1, P r e v a l e n c e of s e l e c t e d t y p e s of i l l n e s s e s per 1,000 p e r s o n s a g e d 6 5 y e a r s and o v e r reporting s o m e i l l n e s s during the four w e e k s before their interviews N u m b e r of p e r s o n s P e r 1/000

Illness Total Total I n f e c t i v e and p a r a s i t i c d i s e a s e s All neoplasms Allergic diseases E n d o c r i n e S y s t e m , M e t a b o l i c , and N u t r i t i o n a l Diseases D i s e a s e s of the B l o o d a n d B l o o d - f o r m i n g Organs M e n t a l , P s y c h o n e u r o t i c , and P e r s o n a l i t y Disorders D i s e a s e s of the N e r v o u s S y s t e m A l l D i s e a s e s of the E y e A l l D i s e a s e s of the E a r D i s e a s e s of the C i r c u l a t o r y S y s t e m D i s e a s e s of the R e s p i r a t o r y S y s t e m D i s e a s e s of the D i g e s t i v e S y s t e m D i s e a s e s of the G e n i t o - U r i n a r y S y s t e m D i s e a s e s of the S k i n and C e l l u l a r T i s s u e D i s e a s e s of B o n e s a n d O r g a n s of M o v e m e n t S y m p t o m s , S e n i l i t y , and I l l - D e f i n e d C o n d i t i o n s S y m p t o m s referable t o r e s p i r a t o r y s y s t e m S y m p t o m s referable to c a r d i o v a s c u l a r and lymphatic s y s t e m S y m p t o m s referable to b a c k and l i m b s N e r v o u s n e s s and debility Headache Other s y m p t o m s , s e n i l i t y , and i l l - d e f i n e d c o n d it i o n s Injuries and P o i s o n i n g s Other I m p a i r m e n t s , A m p u t a t i o n s , a n d L o s s of M e m b e r s

Men

Women

840.8 0.6 12.7 56.5

825.2 0.0 12.5 68.7

854.2 1.1 12.9 46.1

31.1

22.5

38.6

8.7

5.0

11.8

0.6 13.8 241.6 249.1 512.1 188.6 332.8 53.1 5.8 342.0 1,227.2 (145.3)

0.0 10.0 214.7 305.9 367.0 178.5 253.4 67.4 6.2 282.1 1,243.4 (201.0)

1.1 17.1 264.7 200.4 636.6 197.2 400.9 40.7 5.4 393.4 1,213.3 (97.5)

(0.6) (55.4) (19.0) (188.0)

(0.0) (47.4) (8.7) (163.5)

(1.1) (62.2) (27.9) (209.0)

(818.9) 30.6

(822.7) 25.0

(815.6) 35.4

49.0

42.4

54.7

a D a t a are b a s e d o n h o u s e h o l d i n t e r v i e w s d u r i n g M a y — J u n e to the c i v i l i a n n o n - i n s t i t u t i o n a l p o p u l a t i o n .

1957, and refer

Table 2 compares the rates for selected specific diseases secured in this survey and in other recent surveys. For surveys made in New York City and in Baltimore, specific disease prevalence rates were published for heart disease, arthritis and rheumatism, and neoplasms. The illness rates for this sample (identified as the National Opinion Research Center sample) are consistently higher for these conditions than the rates reported in either the New York or the Baltimore studies. Of these three diagnostic categories—heart disease, neoplasms, and arthritis and rheumatism—the symptoms of arthritis and rheu8

Illness, Medical Care, Payments T A B L E 2 . C o m p a r i s o n of N O R C f o u r - w e e k i l l n e s s p r e v a l e n c e d a t a for p e r s o n s a g e d 6 5 y e a r s a n d o v e r , w i t h data for t h i s a g e - g r o u p from other h o u s e h o l d s u r v e y s ( R a t e s per 1 , 0 0 0 p e r s o n s ) Number o f p e r s o n s per 1,000 lItem fem

P e r s o n s w i t h one or more i l l n e s s e s Male Female P e r s o n s w i t h heart d i s e a s e A c c o r d i n g to a d j u s t e d rate^ P e r s o n s with arthritis and rheumatism A c c o r d i n g t o a d j u s t e d rate^ P e r s o n s with neoplasms A c c o r d i n g to a d j u s t e d rate^

N 0 R C

.

RB a lI.· timore 1953-54"

rC a lIi fI o r n i·a 1954-55»·

N e w

Y o r k

«

ο
ο· ο• ι p-Mlfl

00 (Μ _ ris I «

ο Ο ο

ο. ·— u-> r^ oi C"S cJ «to ί-

•»Μ·»-

00 00

ο ο Ο

ΙΟ

ΙΟ I £

to CO ^ • · · CO ^IJJOn '— CO -

II 2 ο

*

I

ι

"ο2 - s2 Ι ° • ok > « J c •£ ο — 3 • ό δ ο Ο—ο ο S£ o μ - ο β ο φ -α ο Ι - (5 IL 0. Ζ Χ I- ώ < ϊ

c α ο Ζ

β ο ο >- Ζ Ζ

Ο C J Μ C r - " W.2 Οΐ Ο £ | ϊ "5 U • β Ο α j Τ3 £ο "I


83.2 62.9 48.6 58.9 24.3 1.4 16.8

73.6 37.9 23.4 53.2 16.6 1.7 26.4

73.0 41.2 26.6 45.0 15.7 4.5 27.0

(286)

(279)

(233)

(574)

77.4 58.9 39.0 50.7 16.4 2.1 22.6

79.3 69.0 34.5 53.4 20.7 3.4 20.7

76.1 52.3 42.0 48.9 13.6 1.1 23.9

69.7 27.3 25.3 53.5 10.1 3.0 30.3

68.7 31.7 29.5 38.5 13.7 6.1 31.3

(146)

(58)

(88)

(99)

(278)

85.4 69.7 48.0 62.8 24.8 1.4 14.6

84.6 71.5 44.7 61.8 21.1 1.3 15.4

86.4 67.5 51.8 63.9 29.3 1.6 13.6

76.9 46.3 22.4 53.0 21.6 0.7 23.1

77.4 50.3 24.0 51.4 17.6 3.0 22.6

(419)

(228)

(191)

(134)

(296)

Total

ί

Total With a s s e t s O w n home or real e s t a t e Life insurance Savings S t o c k s and bonds'9 H e l p of c h i l d r e n or r e l a t i v e s With n o a s s e t s Ν = S h a r i n g a home w i t h r e l a t i v e s With a s s e t s O w n home or real e s t a t e Life insurance Savings Stocks and bonds H e l p of c h i l d r e n or r e l a t i v e s With n o a s s e t s

Ν= N o t s h a r i n g a home w i t h r e l a t i v e s With a s s e t s O w n home or real e s t a t e Life insurance Savings Stocks and bonds^ H e l p of c h i l d r e n or r e l a t i v e s With n o a s s e t s

Ν=

" W h e n both h u s b a n d and w i f e h a v e b e e n i n t e r v i e w e d . a s s e t s are t h o s e reported by the husband.

pared with three of every ten persons in the remainder of the older population, said that they could meet a large bill only through the help of children or public assistance or said, "I just couldn't pay it." Voluntary Health Insurance

In 1957 almost four of every ten persons over 65 had some form of voluntary health insurance. Coverage was more usual among men 74

Employment,

Income,

Cost of Care

T a b l e 49 ( c o n t ' d ) . P e r c e n t w i t h t h i s type o n l y Married couples (head 65 a n d o v e r )

T y p e of a s s e t and l i v i n g arrangement

-o ® c

Total

ο Ϊ Ϊ "a

ϊ s

c 3

S1 π

10.2 5.5 15.7 1.3 0.9 26.4

10.3 6.3 11.3 0.3 2.3 27.0

Total With a s s e t s O w n home or real e s t a t e L i f e insurance Savings S t o c k s and b o n d s ^ H e l p of c h i l d r e n or r e l a t i v e s With no a s s e t s N =

12.0 2.3 6.0 0.2 0.5 16.6

13.6 1.0 5.2 0.3 16.4

10.4 3.6 6.8 0.4 0.7 16.8

(565)

(286)

(279)

(233)

(574)

13.0 4.1 7.5 0.7 0.7 22.6

19.0 1.7 1.7

20.7

9.1 5.7 11.4 1.1 1.1 23.9

6.1 7.1 18.2 1.0 1.0 30.3

8.3 8.3 11.9 0.4 2.9 31.3

(146)

(58)

(88)

(99)

(278)

11.5 1.7 5.5

12.3 0.9 6.1

10.5 2.6 4.7

0.5 14.6

0.4 15.4

0.5 13.6

13.4 4.5 13.4 1.5 0.7 23.1

12.2 4.4 10.8 0.3 1.7 22.6

(419)

(228)

(191)

(134)

(296)

—

S h a r i n g a home w i t h r e l a t i v e s With a s s e t s O w n home or real e s t a t e L i f e insurance Savings S t o c k s and bonds^ H e l p of c h i l d r e n or r e l a t i v e s With no a s s e t s

Ν

=

_

—

N o t s h a r i n g a home w i t h r e l a t i v e s With a s s e t s O w n home or real e s t a t e Life insurance Savings S t o c k s and bon H e l p of c h i l d r e n or r e l a t i v e s With no a s s e t s

Ν includes

=

_

-

-

U . S. S a v i n g s b o n d s , u s u a l l y reported a s " b o n d s "

rather than

"savings.'

than among women and far more usual among the well segments of the population than among the very sick. While the very sick might be expected to be among the heaviest users of hospital facilities, fewer than two of every ten (18 per cent), compared with four of every ten well older people (41 per cent) had health insurance coverage. Among the six of every ten persons who had no voluntary health insurance, about one fourth (16 per cent of all older peo-

75

νΟ •

ο Ε ο >

υ

.5

ο-

Ε° c

ι

r ^ o o « · — O < n o o o < C O O

i j

Μ Μ ^ - β ι Ο ' ί Ο Ο ' - · « ·— Μ ·— —

Ι*» ιη

I M ^ - S O

CO

ο

Ν α η ο η ο · · · · · · · β η - η « ) ' - » w · η

I

ο

• - 0

-ο β Ε ο ο m

>ο -ο

ϊ >

*

Ε

Μ> Ο ~ -ο

gj· s

· •— • ο·» r>» · o> · · • o· ce

Ν coΪ

·ο

·oo ·•—

» o· o· o · o ·o — · · • o · o ·o — CT Μ —— ·— or -· -

·

·

—

·

·

—

·

•

—

·

·

·

·

" >0 m

N i o - ^ o M n m · « » . ' «

sr

^ OOF-»- C 9 W N > CO Ο _

ί * φ

2 ο £

I υ

a. c

Ί g

J? ·>

s

• "

·

§ »

-

Ζ

ο σ b k α. ο 1. "

Μ

§

Ε Ο U C

«

a 3 ο V)


o n · e» o . m• o M

w ο Ρ Ε

0> C

»

>

I κ

Λ

S s -e > · » ί ο

ΰX · C -c ο Ο S * Ο — o>o

.

υ _ ι

ο r -ft

· £ W η 6 » c c

_

—

o

ji

a.

„ J u 3

•-C S ± 3

X ο °· ^

« $·

5

5 . 2 =

0

c

ο 3

* >

g

ο ο - c a ·£ ο ο S I U D . O U Z

*

·

% I _ ° η C ο

* «» c ν

β

i c g 1 2 -»- £ c · L· i T

> ~Ο

β ο

Ο 2 —

* -E · _ 5 6 S5 «·— c σ> ο A ο .Έ 2 υ o> Q . - 0 r k Μ — f

J5 _ ι s

c

x u

α. ο

ο a * _

5 J J

υ

ζ

2

i n i o s c o a M i n s i A n JOOOCO Ό Ν Μ ' - ( Ν Ο

υ .5

5;

β α.

— φ ο Ε ΐβ υ

2 .5 kι.

* η

FΡ

α η Κ Κ Χ η Ν ^ Ν ΐ Ί Ν " » i - O N N O O O N O

Ο· Ν· ΐ ·η ·^ Ό N · O· · ·Ν ·Ο . i n Ό ο α) η ττ Ό I CO ->ί CN r-

— Φ * "2

Ο φ χ

Ο JU · -ο ο .5-ο

Ό ο •ο 0 > φ ΐΤ -Ο s g

< 0 Ν « η m o Ν •»· Ο— Ο t o Ν s

"

Ε

ο .Ε ι

»

Ο Λ !-

ο ο -ε » « £ £ U π C ° α τ; ο

Ii' « 40) C £ C Φ

Λ CO
. Ο α fr β

ό - Ό η •= - 5 Μ β ί 3 Ο Χ Ο Ο -12 I U Q . O U Z

£· w -f

C φ υ Φ α.

The Health of Older People T A B L E 51. 1957

Voluntary health insurance status, p e r s o n s aged 6 5 y e a r s and over, Percentage distribution

m

Insurance status

Total

Men

Women

Total

100.0

100.0

100.0

Insured Not i n s u r e d F o r m e r l y insured Rejected Never applied

38.5 61.4 15.8 2.8 42.8 1,734

42.2 57.8 18.2 2.1 37.5 801

35.4 64.5 13.7 3.4 47.4 933

Ν

=

pie) had been insured at some time in the past. A very small group, about 3 per cent of the total aged, had tried to get health insurance and had been turned down, generally because they were too old or had specific health complaints that made them uninsurable at the time of their application (Table 51). The vast majority of older people who were currently insured said they were covered under a single insurance plan; less than 1 per cent of all older persons interviewed (2 per cent of the insured) reported duplicate coverage. Most insured persons were covered against more than one of the three main types of insured medical costs—hospital bills, doctor bills for care in the hospital, and doctor bills for home and office visits. Almost all (93 per cent) who had health insurance had coverage for their hospital bills; about two of every three reported coverage for doctor bills incurred while in the hospital, and about one person in five had coverage for visits in the doctor's office (Table 52). Only about one third of the persons with health insurance reported that they had complete coverage for any of these costs. For the remainder of the insured, hospital bills, doctor bills in the hospital, or bills for other doctor visits would be only partly paid through their insurance. About half of all persons with health insurance first secured their coverage through employment, either their own or that of their spouse. Such coverage was either required of them or it had been offered to them on a voluntary basis. About one of every five persons with health insurance reported that a salesman had called upon him and sold him the insurance contract. Older people who had secured their health insurance in ways other than through employment—through a salesman, responding 78

Employment,

Income, Cost of Care

TABLE 52. Selected characteristics of voluntary health insurance coverage reported by currently insured persons aged 65 years and over, 1957 Characteristic

Per cent

Benefits Pays Pays Pays all

hospital bills, all or part doctor bills in hospital, all or part doctor bills for home or office visit, or part

93.3 67.0 20.8

How insurance was secured Total

100.0

Employment Salesman Other Don't know

57.0 17.9 19.9 5.1

How long insurance was owned Total

100.0

L e s s than five years Five to nine years Ten years or more Don't know Ν=

24.3 22.4 48.1 5.1 699

to advertisements, or the efforts of relatives—spoke of the function of health insurance in relieving them or their families of worries about hospital bills should these occur. These people stressed the "protection" that health insurance afforded. As many respondents said, "It's a good thing. You never know when you need it." Almost half of all older persons with health insurance had had their insurance for ten years or more (many, of course, had secured their insurance through their work; some said that they had had coverage "since Blue Cross went in and we got it at work"). The reported cost of health insurance to the respondents ranged from less than a dollar a month to twenty dollars or more. Some persons who were still working did not know how much of their payroll deduction was for health insurance and how much was for other benefits. The median cost of health insurance reported by respondents was four dollars a month. Three of every four persons interviewed said that they paid the total costs of this insurance themselves. Other sources of payment for all or part of these insurance costs were present or former employers, trade unions or fraternal orders, and children or relatives.

79

The Health of Older People About a sixth of all persons interviewed had no health insurance at the time of the survey but had been insured at some time in the past. About four of every ten of these formerly insured persons had secured their insurance through their work; about three of every ten had bought it from a salesman (Table 53). Almost half of those formerly insured had terminated their coverage less than five years before the interview, although some persons said that they had given up their health insurance as long ago as fifteen years before the interview. While some respondents might have been vague about the time lapse since they had given up their health insurance coverage, all knew clearly why they had done so. Three of every ten persons who no longer had health insurance had given up their coverage when they or their spouse had retired. Whether these persons had had some option to continue their coverage after retirement and had chosen not to do so is not apparent from their replies. Another three of every ten had given up their insurance coverage because they felt that it was too expensive for them to maintain. Two of every ten had been dissatisfied with the coverage, and about one person in ten had lost his insurance when he was disqualified by the insurance company. Some people who had given up their insurance because they were dissatisfied with its coverage were annoyed and upset by their experiences under voluntary health insurance. Their annoyance resulted from the fact that either they had not realized that

T A B L E 53. C h a r a c t e r i s t i c s of former v o l u n t a r y r e p o r t e d by p e r s o n s a g e d 6 5 y e a r s a n d o v e r Characteristic How insurance was

health insurance

P.rc.ntag. distribution

secured

Total

100.0

Employment Salesman Other

43.4 28.8 27.7

R e a s o n s for t e r m i n a t i o n Total

100.0

G a v e up employment P l a n too e x p e n s i v e D i s s a t i s f i e d with coverage Disqualified Other Ν =

80

27.0 30.7 23.7 8.4 10.2 274

coverage

Employment,

Income,

Cost of Care

their insurance coverage would pay only part of their hospital and doctor bills, or, even if they had understood this aspect of their insurance, they were surprised by the gap between reimbursements under their insurance contracts and the total expenses of hospitalization. All persons who had no health insurance were asked whether they would be interested in obtaining coverage. Half of them said that they would be, but that they could not afford it (34 per cent of the total) or that "they won't sell me any" (16 per cent). One fourth said flatly "I don't want it!" and the same proportion said "I've never thought about it." Those who were already ill and therefore most conscious of medical bills were most interested in health insurance. Seven of every ten very sick persons without insurance would have liked to have such insurance, but five of these seven could not afford it and two of the seven said that "they won't sell me any." Nearly two thirds of all older people said they would like to have insurance covering all medical expenses such as doctor bills, hospital bills, and medicines. The proportion of persons in favor of complete coverage was higher among those who already had some type of health insurance (71 per cent) than among people with no insurance (61 per cent). Apparently once an older person was convinced that health insurance was a good thing, he was more interested than other older persons in expanding his health insurance coverage. Those persons not interested in complete health insurance coverage (about one third of the total aged population) gave a variety of reasons for their attitudes. Some responded in terms of money: they could not afford such insurance or they had enough money to take care of their medical needs. Others responded in terms of their health: they were not insurable or they were rarely sick. About one person in ten among the persons not interested in health insurance (3 per cent of all older persons) objected to the idea of health insurance. All respondents, whether or not they had health insurance, were asked: "Some people think the government should provide insurance that pays doctor and hospital bills. Other people disagree with this idea. Are you in favor of government insurance that pays doctor and hospital bills, or against it?" As Table 54 shows, slightly over half of all older people were in favor of government insurance in 1957. The proportion in favor of such insurance was highest

81

The Health of Older People T A B L E 5 4 . A t t i t u d e s toward government h e a l t h i n s u r a n c e — p e r s o n s a g e d 6 5 years and o v e r a Percentage distribution

Attitude toward government insurance

Total

Men

Women

Very sick

A l l others

Total

100.0

100.0

100.0

100.0

100.0

In favor Against Don't know No answer Ν =

53.5 42.7 3.5 0.3 1,734

55.9 42.3 1.5 0.2 801

51.5 43.0 5.1 0.4 933

65.7 29.7 4.0 0.6 175

52.1 44.1 3.4 0.3 1,559

a B a s e d on a n s w e r s to q u e s t i o n : s h o u l d p r o v i d e i n s u r a n c e that p a y s d i s a g r e e w i t h this i d e a . A r e y o u in doctor a n d h o s p i t a l b i l l s , or a g a i n s t

" S o m e p e o p l e think that the government doctor a n d h o s p i t a l b i l l s . Other p e o p l e favor of g o v e r n m e n t i n s u r a n c e that p a y s it?"

among the very sick; two thirds of them said that they favored government insurance. More persons in poor financial circumstances than persons in average or good financial circumstances were in favor of government health insurance. The lowest incomes among the aged were found among persons who lived with relatives. A higher proportion of these people than of older people living alone or without relatives favored government health insurance (Table 55). Similarly, a higher proportion of people who said their financial status was worse than at 60 than those who said their status was the same or better favored government health insurance. The single most important indicator of the older person's view of government health insurance seemed to be his over-all attitude toward the relationship of the individual and government. In a section of the interview separate from the section on insurance respondents were asked, "Who should take care of older people when they are no longer working?" Among those who said that the older person should provide for himself, only one third were in favor of government health insurance. Among those who thought that children and relatives should take care of older people who were no longer working, almost half favored government health insurance. Among those who thought that "the government should take care of older people," whether through Social Security or other means, two thirds were in favor of government health insurance. Those older persons who believed that the government should assume welfare responsibilities were more likely to favor government health insur-

82

Employment,

Income, Cost of Care

T A B L E 5 5 . A t t i t u d e s related t o f i n a n c i a l s u p p o r t — A l l p e r s o n s a g e d 6 5 y e a r s a n d over a n d t h o s e w h o favor government h e a l t h i n s u r a n c e L i v i n g arrangements and attitudes

a||

res ondents *

P e r cent of t h o s e in Ivor ooff ggoovveerrnnm meennt L aem h a lt+U t h Αi nΜsΛuIrι·Μ a nμc e

,avor

L i v i n g arrangements Total S h a r i n g a home w i t h r e l a t i v e s N o t s h a r i n g a home w i t h r e l a t i v e s Who should when

take care of older they are no longer

100.0

53.5

34.4 65.6

59.8 50.3

people working?

Total S h o u l d p r o v i d e for t h e m s e l v e s C h i l d r e n or r e l a t i v e s Employer pension plan Government through s o c i a l security a n d other methods Other a n d n o a n s w e r

100.0

53.5

23.7 26.2 3.9

37.7 46.7 60.3

41.3 4.8

67.2 45.2

100.0

53.5

45.4 15.1 37.3 1.2 1.1

49.9 45.4 61.2 °

How are you getting along financially compared with when you were 60? Total A b o u t the s a m e Better Worse C a n ' t compare No answer

0

" P e r c e n t s not computed w h e n b a s e i s l e s s t h a n 2 5 ·

ance than were persons who felt that the individual should assume these responsibilities for himself. Those persons in favor of government health insurance were asked whether they were in favor of it for everyone or just for certain kinds of people. About half (29 per cent of all persons interviewed) favored government insurance for all people; the remainder felt that such insurance should be available for persons who could not afford voluntary health insurance or for elderly or disabled persons. Payments of Medical Costs

The discussion to this point has been concerned with how older people thought they could pay a large medical bill if confronted by one. Information was also secured on the actual financial resources 83

The Health of Older People from which people did pay medical bills during the four weeks before they were interviewed and the sources to which they had turned to meet hospital bills incurred during the survey year. Three of every ten respondents had consulted a doctor outside of a hospital during the four weeks before their interview. Seven of every ten who had consulted a physician (19 per cent of all older people) paid the doctor for his services from their own resources (Table 56). In most instances these older persons paid the doctor from their current income or their savings; in a few instances payments were made through insurance coverage or in some other way. About two of every ten persons who had seen a doctor (8 per cent of all older people) stated that they personally had not made any payments to a doctor for his services. Children or other relatives or welfare or charitable organizations had paid for some of them, some were given free care by a physician, and some reported that they had received free care through government hospitals or in other ways (Table 56). The reported experiences of respondents in meeting the costs of physicians' care during the four-week period are probably more reliable than answers to over-all questions about free care during the survey year. It may be recalled that twelve of every one hundred respondents interviewed (about 8 per cent of all older people) reT A B L E 5 6 · H o w older p e o p l e p a i d current doctor b i l l s — R e p o r t s of p e r s o n s aged 65 years and over with out-of-hospital contacts with p h y s i c i a n s during the four w e e k s before the i n t e r v i e w s Percentage distribution

M e t h o d of p a y m e n t Total

100.0

Older person paid p h y s i c i a n T h r o u g h income or s a v i n g s In s o m e other w a y No answer

69.4 60.3 6.7 2.4

Older p e r s o n d i d not pay p h y s i c i a n C h i l d or r e l a t i v e paid Welfare or c h a r i t a b l e o r g a n i z a t i o n p a i d D o c t o r took no fee Other r e a s o n

21.9 6.1 7.4 3.8 4.6

N o answer

8.7 473

Ν

=

" T h e s e t a b u l a t i o n s differ s l i g h t l y from t h o s e in T a b l e 16· T h i s i s d u e to s i x p e r s o n s w h o reported earlier that t h e y h a d p a i d the doctor p e r s o n a l l y , but w h o s e c h i l d r e n or r e l a t i v e s were later reported a s h a v i n g paid the d o c t o r .

84

Employment,

Income, Cost of Care

ported that they had received medical or dental care for which they personally had made no payments during the survey year. This care had been furnished by welfare or charitable agencies for seven of every twelve of these respondents; children and relatives had assumed the costs of care for five of every twelve respondents. Older people who received medical care during the four-week period reported that welfare agencies and children and relatives had contributed to their care at about this same level. In addition, these older people reported that individual physicians had given them free care and that they had received free care through government hospitals or in other ways. Apparently, the answers to the over-all question on noncash assistance during the survey year underreport the number of older people who received medical or dental care for which they made no out-of-pocket expenditures. Two types of free care seem to have been underreported: free care given on a personal basis by the individual doctor, and care received by veterans through a government agency. The very sick were less likely than other older people to pay a doctor for his services. Thirty-three per cent of all very sick persons who had seen a doctor during the four weeks before the interview said that they did not pay the doctor for his services; only 19 per cent of all other persons reported that they personally did not pay the doctor. Eight of every ten stays of older people in short-term hospitals were paid for by the older person from his income, his savings, or his insurance coverage, or with the help of his children and other relatives (Table 57). Physicians were reported to have been paid for their in-hospital services in about the same proportion of hospitalizations and from the same sources. About half of all persons who reported that they had paid their hospital bill and their physician fees said that they had drawn on more than one source in meeting these bills. Older people reported that insurance payments had enabled them to meet part or all of their hospital bills in 45 per cent of all hospitalizations, and part or all of the physicians' fees in 30 per cent of all hospitalizations. Children and relatives helped older people meet their hospital bills in 14 per cent of all reported hospitalizations, and their physicians' fees in 12 per cent of all cases. Charitable or welfare organizations were reported to have assumed hospital and physician costs in about 15 per cent of all hospitalizations in short-term hospitals. 85

The Health of Older People T A B L E 5 7 . H o w older p e o p l e p a i d h o s p i t a l s a n d p h y s i c i a n s — R e p o r t s of pers o n s a g e d 65 y e a r s a n d o v e r w i t h h o s p i t a l i z a t i o n d u r i n g the s u r v e y y e a r Percentage distribution

M e t h o d of payment to hospitals and physician

Total"

Men

Women

100.0

100.0

100.0

83.4 23.3 32.1 44.6 14.0 1.6 16.6

82.0 25.0 34.0 46.0 12.0 2.0 18.0

84.9 21.5 30.1 43.0 16.1 1.1 15.1

15.0 1.6

15.0 3.0

15.1

100.0

100.0

100.0

81.3 25.4 36.3 29.5 11.9 1.6 18.7

79.0 29.0 34.0 32.0 9.0 3.0 21.0

83.9 21.5 38.7 26.9 15.1

15.0 1.6 2.1 193

14.0 3.0 4.0 100

16.1

To hospitals Total P a y m e n t s m a d e to h o s p i t a l Income Savings Insurance C h i l d or r e l a t i v e B o r r o w e d money N o p a y m e n t s made t o h o s p i t a l W e l f a r e or c h a r i t a b l e organization Employer

—

To physicians Total P a y m e n t s made to p h y s i c i a n s for s e r v i c e s w h i l e h o s pitalized Income Savings Insurance C h i l d or r e l a t i v e B o r r o w e d money N o p a y m e n t s made to p h y s i c i a n s Welfare or c h a r i t a b l e o r g a n i z a tion Employer N o fee charged Ν =

—

16.1

—

93

° P r o p o r t i o n s b a s e d on number of a d m i s s i o n s , not on number of p e r s o n s ( 1 9 3 h o s p i t a l i z a t i o n s , 181 p e r s o n s ) . P e r c e n t s do not a d d to s u b t o t a l s s i n c e a n ind i v i d u a l may h a v e made p a y m e n t s to the h o s p i t a l or to a p h y s i c i a n from s e v eral s o u r c e s .

The Reported Need for Medical Care

To what extent do older people feel that needed medical care is not available to them? Answers to this question were sought in several ways—through investigating why respondents had not seen doctors for specific illnesses and health complaints, through encouraging respondents to speak about any aspects of their health care which they felt were being neglected, and by specifically asking respondents whether there were any things they needed which they had had to do without because of lack of money. 86

Employment,

Income, Cost of Care

Seventeen of every 20 persons interviewed in this survey (84 per cent) reported at least one illness or health complaint during the four weeks preceding their interview. Only one third of these persons, however, said that they had seen a doctor or talked to one over the telephone. The reasons people who reported an illness had not seen a doctor are given in Table 58. Regardless of the nature of their complaints, the main reason older people had not seen a doctor was that they did not think they were sick enough to require a doctor's services. Many persons said outright that they were not sick enough for a doctor; a substantial number felt that they could treat their illness as well as a doctor could; and some persons thought that a doctor did not seem able to treat their illness. A number of older people gave vague reasons for not seeing a doctor that hinted at their feelings that they "shouldn't bother the doctor." These replies from the aged explaining why they do not see doctors must be interpreted in light of the attitudes of older people toward their own health and toward the medical profession. It seems correct to say that most people do not see doctors because, despite the many illnesses and complaints of the aged, most older people do not think they are really sick. The illnesses and complaints of the aged are largely chronic conditions of long duration. Most older people take these complaints for granted and accept the discomforts as part of normal existence. After all, many respondents agree that "older people have to expect a lot of aches and pains." Further, there

T A B L E 58. R e a s o n s for not s e e i n g a d o c t o r — p e r s o n s o v e r ( w i t h reported i l l n e s s

a g e d 65 y e a r s

Percentage distribution

R e a s o n for not s e e i n g doctor Total

100.0

I l l n e s s h a s not bothered r e s p o n d e n t e n o u g h to s e e doctor R e s p o n d e n t c a n treat i l l n e s s a s w e l l a s doctor c a n D o c t o r d o e s not s e e m to be a b l e to treat i l l n e s s C a n n o t afford doctor Other r e a s o n s R e a s o n s too v a g u e to c l a s s i f y or No answer

Ν=

87

43.4 15.2 9.8 5.6 3.7 22.4 765

and

The Health of Older People is a general belief among the aged that a doctor should be consulted only for an acute illness. Most older people believe firmly that "a person understands his own health better than most doctors do." Unless an older person thinks that he is seriously ill, he will not consult a physician. Only one person in twenty among those who had reported a current illness—about three persons in every one hundred in the older population—said that lack of money was keeping them from medical care. Later in the interview, however, about eight persons in every one hundred reported that they were dissatisfied with some aspect of their health care, and still later, when asked whether there was anything they were doing without because of lack of money, about eight persons in every hundred said specifically that they were doing without medical care. Both groups—those who felt that their health was not being taken care of properly and those who felt that they were doing without medical care because of lack of money—included high proportions of the very sick. After a series of questions about their health, respondents were asked "Is there anything [else] about your health that you feel is not being taken care of properly?" For the two groups, the very sick and the remainder of the population, one in four and one in sixteen, respectively ( a total of eight of every one hundred persons in the older population), thought that something about his health was not being taken care of properly (Table 5 9 ) . Some of these older people thought that they should have medical or dental care, appliances T A B L E 5 9 . C o m p l a i n t s about h e a l t h c a r e among the v e r y s i c k and all other older p e o p l e 0

Complaint

P e r cent of all persons

P e r cent of v e r y sick

P e r cent of a l l others

8.2

24.0

6.5

5.5

18.3

4.0

3.9 1,734

16.0 175

2.6 1,559

S o m e t h i n g about h e a l t h not b e i n g cared for properly N e e d m e d i c a l care in order to h a v e better h e a l t h Not r e c e i v i n g proper care b e c a u s e of lack of money Ν =

" B a s e d on a n s w e r s to q u e s t i o n s : I s there a n y t h i n g about y o u r h e a l t h that y o u feel i s not b e i n g t a k e n care of p r o p e r l y ? What do y o u feel s h o u l d be d o n e about i t ? W h a t ' s k e e p i n g y o u from d o i n g t h i s ?

88

Employment,

Income, Cost of Care

such as glasses or dentures, or special medication to improve their health or to meet their health needs. A few persons said that they needed more money to enable them to have better living arrangements or better food which would in turn result in an improvement in their health status. A substantial number of persons said that they did not know what should be done to improve their health. Four of every hundred older persons (one of every five very sick persons, and one of every twenty-five persons in the remainder of the older population) said that they felt their health was not being taken care of properly because they could not afford adequate health care. Some among those who previously had said that they needed medical care in order to improve their health made no mention of lack of money in explaining why they were not receiving such care. Instead, they said that they had not sought medical care because they felt that they could keep going without such care or because they felt that a doctor could not really help them. Some persons who had mentioned that they needed surgery to be in good health reported that they were afraid of surgery and would go without it as long as they could. In designing the interview schedule it had been expected that some among the older population might hesitate to mention their poor financial status as an explanation of why they were not interested in medical care for current illnesses or for improving their over-all health. It was decided, therefore, to include a direct question to the aged on deprivations attributed to lack of money. Well along in the interview, after detailed discussion of finances and the problems which older people faced in living on a limited income, all respondents were asked: "Are there any things you especially need that you've had to do without because you don't have enough money?" Twenty of every hundred persons in the older population said that they had needs of varying kinds which could not be met because they did not have enough money. Only eight of every one hundred persons in the older population specifically said that they needed medical or dental care. Among the persons who said they needed medical care, one of every three had previously been classified as very sick. One of every four very sick persons and one in sixteen in the remainder of the older population said that they were doing without needed medical care because they had no money. Table 60 gives some of the characteristics of that group of the 89

The Health of Older People T A B L E 6 0 . S e l e c t e d c h a r a c t e r i s t i c s of p e r s o n s a g e d 65 y e a r s and ov porting unmet m e d i c a l n e e d s due to lack of money P e r cent with g i v e n characteristic

Characteristic M a i n i n c o m e from p u b l i c a s s i s t a n c e Total

38.6

Very sick Others

40.5 37.8

Attitude toward doctors A p e r s o n u n d e r s t a n d s h i s o w n h e a l t h better than most doctors

71.4

L a s t s a w doctor Total

100.0

Within l a s t four w e e k s Within 1 - 1 1 m o n t h s O n e y e a r or more

Ν

55.0

20.0 25.0 140

=

aged who felt that they needed medical care they could not afford. The composition of the group is somewhat surprising. Two of every five reported their main source of income as public assistance. Older people on public assistance in most states receive some sort of medical care if needed, although the level of care varies widely from state to state. Further, almost six of every ten of all people who said that they could not afford medical care had seen a doctor in the four weeks preceding the interview. The 8 per cent of older people who needed medical care but were doing without it because of lack of money were not a homogeneous group. Two distinct kinds of individuals felt that they were not receiving medical care because they lacked money. One group (about 3 per cent of all older people) were already receiving some kind of care through assistance programs. Their feelings about doing without medical care were really criticisms of the adequacy of their care. Their attitudes would appear to be expressed in the phrase "If I had more money, I could go to a better doctor." Some of this feeling is suggested in the high proportion of all persons with unmet medical needs (71 per cent) who agreed that "A person understands his own health better than most doctors do." Another group (about 5 per cent of all older people) was not receiving free care. These per-

90

Employment,

Income, Cost of Care

sons apparently had a valid basis for their feelings that they were not receiving medical care because they could not afford such care. The data secured in this survey indicate that most older people do not feel they are being deprived of needed medical care on a day-today basis because of lack of money. The proportion of all older people who specifically mentioned money as a deterrent to medical care and who were not already receiving care was only 5 per cent of the aged population. During the four-week period preceding the interview 22 per cent of all older people who saw physicians made no personal out-ofpocket payments to physicians. During the survey year the costs of 15 per cent of all hospitalizations of the aged in short-term hospitals were assumed by welfare or charitable agencies, and the costs of an additional 12 to 14 per cent of hospitalization were assumed in whole or part by children and relatives. The 5 per cent of the aged who said that they could not afford medical care must be considered as a group of medically indigent who exist in addition to the roughly 20 to 25 per cent of the non-institutional aged whose medical costs were already being met by children and relatives, or by welfare agencies and various other sources of free care. Summary

The millions of people in the United States who are 65 and older are often considered as though they were all alike. There are wide differences within the older age group, however. Some of these differences have been indicated in the present analyses of the employment and income levels of the aged and in the discussion of the experiences of the aged in meeting the costs of medical care. Some older people interviewed in the survey were employed; most had already retired. Only about three of every ten older persons reported that employment, either their own or that of a spouse, was their main source of money income in 1956. The incomes of older men and women who were employed were higher than the income level of the remainder of the older population. As might be expected, couples and individuals whose major income was derived from employment were more optimistic about their financial status than were other aged persons. The actual money income received by most aged persons in 1956 was lower than the income of other segments of the population. Median incomes reported in this study were less than $1,000 for un-

91

The Health of Older

People

married women, slightly more than $1,000 for unmarried men, and less than $2,500 for married couples. The lower the income of the older person the more likely he was to report that his income had been supplemented through noncash assistance in the form of food, clothing, and free medical and dental care. Unmarried older men and women sharing a home with relatives (largely a group of widowed parents living with their children) were most likely to report such income supplements. Although no questions were asked about free housing, many of these older persons were undoubtedly living with their relatives, rent-free. Older people themselves, through their income and savings supplemented by health insurance, met most medical care costs associated with visits to doctors, hospitalizations, and physician services in the hospital. For about 20 to 25 per cent of the older population (one person in four or five), however, these costs were being met in other ways: by welfare or charitable organizations, through the assistance of children and other relatives, by free care given by individual physicians, or by some other form of free care. About one person in twenty in the older population (5 per cent) reported that he was doing without needed medical care because he lacked money for such care. These persons appear to form a marginal group who were not welfare or assistance clients, but whose money income was so small that they could not afford expenditures for medical care. Although most older people were meeting the costs of occasional or routine medical bills themselves, a substantial group of the aged were concerned whether they would be able to make expenditures for medical care should they incur a bill as large as $500. About two of every five older people (twice as many as those already reporting free care and care paid by children and relatives) apparently could meet such a bill only by mortgaging their homes, borrowing on their life insurance, or by calling on their children and relatives or welfare agencies for help. In general, the "very sick" group in the older population seemed the least able to pay for medical care. Many of these persons were already receiving substantial free care and services. The income of the average very sick person was so low it seems obvious that his continued existence outside of an institution was possible only because of the economic as well as other forms of help given by relatives and health and welfare agencies.

92

Employment,

Income, Cost of Care

Slightly more than half of all older people were in favor of government health insurance in 1957. In general, those persons who felt themselves to be in a precarious or poor financial position were more likely to be in favor of government health insurance than those persons who felt their financial status was as good as it ever had been. Even more important than finances as an indicator of whether an older person would favor government health insurance was his or her over-all attitude toward the functions of the federal government. Those persons who felt that the federal government should assume broad responsibilities for the level of support of its older citizens were more likely to favor government health insurance than those persons who felt that the individual should assume these responsibilities himself.

93

ν The Living Arrangements of Older People Older people in the United States usually maintain their own households apart from their grown sons and daughters. This style of life is the result of many factors, among them increased urbanization, greater national mobility, and, most important, cultural values which stress independent living for the older person as long as possible, and independent living for adult children.1 Contrary to popular belief, however, most older people are not physically isolated from their children. Findings from this survey show that most older people who have children live close to at least one child and see him often. Further, many older people who have no living children do have young relatives whom they see often and to whom they would turn in time of need or illness. Despite these facts, the American public and the American press share a common view of the elderly. One popular stereotype of the older person in this country is the sick old man or woman who lives alone. Robert Reese illustrates this stereotype. Mr. Reese is 66, has never married, and lives alone in a small apartment in a mediumsized town. He is in poor health, suffering from a heart ailment, high blood pressure, hardening of the arteries, emphysema, sinus trouble, and increasing deafness. Because of his failing health, Mr. Reese gave up working before he reached the compulsory retire1 The importance of cultural values in determining the living arrangements of the aged is discussed in Henry D. Sheldon, The Older Population of the United States (New York, John Wiley & Sons, Inc., 1958).

94

Living Arrangements

of Older People

ment age in his industry. He reports that he "has been under a doctor's care constantly for five years." He feels that his health is "worse" than the health of most people his age. Mr. Reese has no close relatives. Men he worked with in the past call on him occasionally. He told the interviewer who visited him, "I don't even have one real friend." The interviewer's comments about him were that "He talked about his illness regardless of the questions I asked him. He seemed a sick man, tired of life, with no relatives of any kind." Mr. Reese is almost a perfect example of the widely held stereotype of the elderly person who lives alone. To fully conform to American folk belief, he should live in a large city in a single room, instead of in a medium-sized town in a small apartment. Mr. Reese and others like him do exist among the older population. However, they are only a small minority of the aged. Most older people do not live alone, and most do not think of themselves as sick. Four of every five older persons in the United States living in the community are in a household with other people. Most often these other people are relatives—a husband or wife, children, or other relatives by blood or marriage. John Craig illustrates a more usual type of living arrangement among older people, particularly among older men. Mr. Craig is 72. He has been married for forty-nine years, and he, his wife, and an unmarried son live in their own home. Mr. Craig is a master plumber. Although he describes himself as "retired," he still takes an occasional job. Mr. Craig terms his health fair. Until recently he would have said it was "good," but within the last six months he has lost his appetite and his "stomach" has begun to bother him. Mr. Craig says his relatives visit him often. Further, "all our neighbors are good friends." There are from six to ten people in his immediate neighborhod whom he thinks of as "real friends," although he has fewer friends now than he had at forty because "I don't go to all the places and associations I did then." The vastly different lives of Mr. Reese and Mr. Craig illustrate the wide variation among older people in the United States in living arrangements and attitudes. Table 61 summarizes the living arrangements of all non-institutionalized older men and women, with and without children. In general, the living arrangements of men over 65 differ markedly from those of women; similarly, the living arrangements of people with children differ from those of persons without children. Any discussion of the living arrangements of the

95

·» Υ £ Ο.

Ο Ο Ο

ΙΟ Ν CO

Ο Ο Ο

Ο CO CM

CM (-»

Ο Ο Ο

CO CO

CM CO N M | | CO CO

Ο Ο Ο

CM CM CM

·— •V

CO Ο —

CM CM R- Ο ·-; O> V CO CM ·— CO Ν -F CM CM

Ο Ο Ο

00 Ό* ·—

Ο ^ Β CO Ο Ν Α ΙΟ W ^ ΡΊ LORT^R-

Ο Ο Ο

—_ ΙΗ «Ν

R- R·. Ν Ο Ν. Ν. ΟΌ Ι*» Ι*» I"» Ο CM CM

CO CM S A

1

1

SLJI IO ^ 1 1

-O 1 CO'

1

IO I Ό'

1 1 1

1

1 1 1

Ν CM Ό Ο O' CO •— —

Ν ·— Ό » O » CN — Ι-

« « O •O ·» CM"

1 1

ΟΝ *0 CO CO V CO — CN

ΙΟ Ο • CM Ο CN

N O W

« Ο. —

ΐ · » 2 « Χ

Ο TF ·—" CM

° Ο CN —

• CO CO CO 2 Η ·Ο -Φ —' Ο!

Η •

£

ΙΟΝ Ο 2

C U 2 ?

O S N CM

>0 CM ΤΓ .' Ο Ο

Ο Ο Ο CO Ο» Ο» CÖ CÖ "Ι Ν CM ΤΤ

^ Q Ο CO

Ο; Ό ·» IO'M'D

CM OF2

> HI

Ο Ο Ο

^ Ο CM

-Ο 0> CO ΙΟ CO (Ν -Ο CM* >—' Ο ΓΟ ΙΟ CO F— —

CO
--5: Ο .* '•5 . — "Ο 3-S 3 ο ί ΐ 0 JΜ 5 *2 .Ε « χ ί U » i £ * Μ » · β

t •Ε I •8

fc> ο •β ο -C

R III"

-J to .2 ~ *Λ

S

ο ο ο οο S Ι Ι Ϊ Ζ

*i Λ~ ο ο. J ο C Ο•π,ϊ- --Κ cΤ)ηΟ * ο ο ϊ . *- -Ε (See* !? μ « » 3 « .. οοο

c°

ε

ο ηβθ'»'θ0ι 15 ο* ο*»— Ζ> χt ο_ 5 «ä ° t1* ι·« 1 &1 oΜ Χ JL. S· ° ·- U « 1.Ο StrS* • S( >I C-κ i cf £ • ίΐΰϊ χ £ >· · > *Μ Μΐ ·Μ*• 3 β* Ο » 5 = 61 οC ο>2 >. c " g —ο C -w C Jf ο -= ο ·= ο ,ΐ CT) β3 3 1 Ü J Ϊΐ^β σ •m i« j;- iι g i s s * ο ο ο ο ο ο ° 3 · ι! I- 3 2 2 S Z ö «χ χo -Β

Older People and Their Families pected" responses of older people and their sons and daughters are much more realistic assessments of parent-child relationships.3 The "What should Mary do?" question was a very real one for the respondents, whether older people or the individuals to whom they would turn in a health crisis. The answers to this question apparently represent the real solutions generally followed by Americans in comparable situations. When an older person is sick, he moves in with or close to a son or daughter. Do Parents Come First?

Despite the common American belief that sons and daughters assume little or no responsibility for their aged parents, data from this study show that older people, their sons and daughters, and the public generally believe that adult children should assume certain responsibilities for their aged parents. Three narrative "hypothetical questions" were devised to deal with the choices adult sons and daughters must make against a backdrop of their parents' needs, wants, or desires. In the first question the choice was between a son spending his leisure time in recreation or in repairing his parents' home; in the second, a man had to choose between helping his wife with the family shopping or accompanying his mother to the doctor; in the third, a man had to choose between being at home with his family on Easter Sunday or visiting his parents on that day. All three questions were, in effect, "Do parents come first in these situations?" Table 75 presents answers to the dilemma of Jim, the adult son who had to choose between recreation and helping repair his parents' home. This question was asked separately of older people and responsible individuals. The complete question follows. Mr. and Mrs. Williams are in their seventies. Their roof started to leak a couple of weeks ago, and their son Jim said he'd come out and fix it when he had a day off. They were expecting Jim Saturday, but he called and said that he didn't know if he could make it, because his bowling 9 In the subsample 35 per cent of older people with sons and daughters and 32 per cent of their responsible relatives agreed that "most of the time, lots of people who share a home with their children feel that their children don't really pay any attention to their advice." An additional 42 per cent of all older people and 55 per cent of their children agreed that this situation was true "some of the time." Three of every four older people and four of every five of their adult sons and daughters, then, are aware of this potential conflict situation.

123

The Health of Older

People

T A B L E 75. M a i n t e n a n c e of p a r e n t ' s home v e r s u s r e c r e a t i o n — C h o i c e s of pers o n s a g e d 65 y e a r s and o v e r , and of r e s p o n s i b l e i n d i v i d u a l s " Percentage distribution -What

should Jim

Total Go Fix Get No

Older People

do?"

bowling the roof s o m e o n e to fix the roof answer N =

All responsible individuals

Total

With living children

With n o living children

100.0

100.0

100.0

100.0

13.8 68.4 8.8 9.1 1,734

14.7 67.9 8.6 8.9 1,350

10.7 70.3 9.4 9.6 384

17.5 68.3 12.4 1.8 1,405

" B a s e d on a n s w e r s to the q u e s t i o n : " M r . a n d M r s . W i l l i a m s are in their s e v e n t i e s . T h e i r roof started to leak a c o u p l e of w e e k s a g o , a n d their s o n J i m s a i d h e ' d come out a n d fix it w h e n he had a d a y off. T h e y were e x p e c t i n g J i m S a t urday, but he c a l l e d and s a i d that he d i d n ' t k n o w if he c o u l d m a k e it, b e c a u s e h i s b o w l i n g team from w o r k i s p r a c t i c i n g for the tournament then. What s h o u l d Jim d o ? "

team from work is practicing for the tournament then. What should Jim do? As Table 75 shows, both older people and their responsible relatives felt strongly that Jim should fix his parents' roof or get someone to fix it in preference to going bowling. Table 76 compares the answers of the older people who named individuals they would turn to for help with the answers these individuals made. As this table shows, older people with children appear slightly more likely than older people without children to suggest that Jim go bowling. Some parents felt that Jim should go bowling "Because it's important . . . it has to do with his work . . . " The replies of those older parents who said that Jim should go bowling reveal an uneasy undertone, however, as if many of them really felt that Jim should fix the roof but would not say so openly. As some of these older people told the interviewers, they did not want to seem to be "selfish" or "inconsiderate" parents. Since the question about Jim had to do with home maintenance, perhaps the replies should be interpreted not as "parents come before recreation," but as "property is more important than recreation." The data indicate, however, that older people and responsible individuals seemed to feel that by going bowling Jim would be neglecting his aged parents, not merely their roof. This point of view was clearly expressed by the 15 per cent of all older people and by 124

ΐ

s °

S

ο

Ε " ί α · > χ

Ο LO Ο Γ^ f 00 ^ ·— CO •— Ό •— υ

> -ο

c c w

>.

3

-Ο ® Ε jο r

_Φ -Λ

"C ο « Ϊ $ α

_

Ε ι- βί -£ ·- Ξ ) ; u

0 00* 00*— r-' ^ Ζ —

β

ο'5: J® TJ ΟΟ. C Ο 3 0 -Ο

Ο ς Μ

CH

Ε ο -Ε

σ) Φ ο -c - J

ο 3 Τ)

J ο

"ο

i ^ο

•Λ Ο €0 1Λ t^ α> 0>ί 2 ·— Ο »— Λ.

ο Η

φ W) ο -C

TS-a ο Ο -C t >.» ο ο - 15 «φ =• ··2·" ·- Ε

: «

0 η

1 a

_o α ο ο

Ο ο Ο

I«. ο ο ο οΓ«Ν οί m r£

. « Φ c φ

Ζ 3 υ ο φ α. Φ Χ Φ

Φ « *

i ο -C υ

t

§ -ο β

> ©>

ο « = Φ— Q. φ

S 5 · « L C ο ο -Ό α. ~ V) Ο ν

> L. £ £

*

- -ο . ί -

Ο ο Ο

Μ Ο >0 CM Ό in oö od oö !Ζ ·— Ό .

§

. 2

£ ?

.5 Ι - υ ο α Μ ο Ε

ο " „-ο

ο J

5

β ϊ ; ϊ

ο

os r·» η

ui

Μ-

!

" ^ 5 -ο C ο j ί :

φ .r c O χ ) *„

C Ε σ Φ Ü f J ϊ οj Μ

.1-5 § S 3 5-οο I ο

2 "5 ο •C - 2 5 « " i j ία
> ·— J* C ο ο η "c IL Μ Φ k Χ 0 ο ο •β 0ί Φ Ό •C ία• Μ _c S φ Μ 5 3 «οιι 0 C c υ Φ _c . 0 II] 4φ' ·» φ . 9 ο CT φ φ Ε. • > JC χ » b- -C ' φ > Η. ^0 φ Μ *ϊ C Ο φ Κ Ε λ c φ φ σ ο φ -ο , «Β ΜJC ί- — b -ο Ο Je ' φ * * · C 0> WC ο C ο ϊ CO ο σ α on

α α ο

5 ~ * 3 JC « -C Μ

α:

α ο • α

ε ;

- Τ ο ο 3 Τ> m

-Ο V) £ C xυ ο Ο Μ ·- Γ4ί " Ε ϊ β χ ε ί α. • t C Ϊ 0 ΧΟ ·So-"-· • μ η ϊ fc. 0 α h η >> Ο ^ • M l o> "Ό φ Μ 'cΓ cΦ ο ο m ο "J ο •. » k S > Ηb Μ _ι ϊ —ο χ ο α >.» -S-τ® c π < ' i-2 Ιι- Λ > ω ζ 2

The Health of Older

People

do you think should take care of older people when they are no longer working?" Among older people, one of every four believed that an older person should provide for himself when he was no longer working (Table 81). These respondents often told interviewers that prudence and thrift in youth and middle-age would enable older people to support themselves in old age. No one then would have to take care of their financial needs; they should be able to take care of themselves. The majority of older people, however—three of every four —apparently did not feel that an older person could accumulate enough savings during his working life to make him self-sufficient in retirement. These older persons either felt that sons and daughters should support older people, or most often that the government should provide for the aged through Social Security and other income maintenance programs. The public cross-section, representative of Americans of all age groups, was less sure than older people that the elderly should support themselves when retired. The public felt either that children and relatives should support older people, or most often that the government should take primary responsibility for the financial support of the aged. The replies of responsible individuals differed from those of both older people and of the public. Responsible individuals were less likely to say that an older person should take care of himself or that the government should take care of him when he is no longer working. They were more likely to say that sons, daughters, and other relatives should take care of older people who were no longer working. The sons and daughters of older people were most likely among all the groups to say that children should support their parents (Table 82). In contrast, the parents of these same individuals were the most likely of all groups to say that the government should assume primary financial responsibility for the aged. Two of every five older people with sons and daughters felt that the government through social insurance and other methods should support older people; two of every five of their sons and daughters felt that the support of older people is their children's responsibility. Older people, responsible individuals, and a public cross-section were asked to comment on a hypothetical situation focused on financial responsibility for aged parents. The question, which de132

— -ο

β ?

α.

«

Ο

« Μ Ι Α

S

O N • » Ό c j c x S

α χ

_0

i

s «

-

ο

ο>

ο Ο

N o ' w i — ->f

· «ο ι>»

*

3 .

ο : >.·>•· ο •Β

O -

S ο

ψ "

ο £ 3 Ο 3 u α

ε' 2 1 ' .ι· 0 « VI ί

Ε • _C

ί

1-

00

(0

Γ·


-c

Ο ο ο

"Ο 1 α ο Μ 'μ ™ i

*

ο

S

ο *

ο -C ϊ

ο C O»

ο

*-

. s " Ο O..C > _ α Ο J 3

. ο ; ϊ

4-

« —

"Ο

£0 < I-

β Ε Ε

ο- Ε « β _ c *j:

"5 Ο Η

^

s

8ο α -Ο " 5 ο _c «Λ

βο

«ι

β jt ο

ο s

w e · ϊ i Ξ - 5 . — Γ -C Ε UUJ

β β E ·• > ο Ο

i

ο C

CTJ c c 5 ° £ β ο ^ »· Ο

3 Ο >· Ο

Older People and Their

Families

scribed the dilemma of a Mr. Brown, was upsetting to a few older respondents. Many identified themselves completely with Mr. Brown. A number of older women answered the question in terms of "Mrs. Brown," telling the interviewers what "Mrs. Brown" should do under the circumstances. Mr. Brown is a 70-year-old widower. He worked hard all his life, until he had to retire, but with the depression and raising a family, it's been difficult to save very much. Now it looks as though Mr. Brown is going to need regular money help. Mr. Brown has two sons and a daughter, all married, and with small children of their own. All of them are managing all right, but with the way things are now, they feel they are just getting along. Who do you think Mr. Brown should ask to help him—a welfare agency, the government, or his children, or someone else? (Why do you feel this way?) A majority of all three groups said that Mr. Brown should ask the "government" or a "welfare agency" for financial assistance (Table 83). Older people who had children were the most likely of any group to give this answer and the least likely to suggest that Mr. Brown ask his children for help. While a majority of responsible inT A B L E 83. Who s h o u l d take f i n a n c i a l r e s p o n s i b i l i t y for a g e d p a r e n t ? — A n s w e r s of p e r s o n s a g e d 6 5 y e a r s and o v e r , of r e s p o n s i b l e i n d i v i d u a l s and of public c r o s s - s e c t i o n Percentage distribution " W h o should Mr. Brown ask to help him?"

Total Children Welfare or government No answer N =

Older people

All responsible individuals

Public crosssection

100.0

100.0

100.0

37.0

42.4

34.9

55.0 8.1 384

53.2 4.4 1,405

60.0 5.0 2,567

Total

With 1 iving children

With no 1 iving children

100.0

100.0

31.4

29.9

60.8 7.7 1,734

62.5 7.6 1,350

" B a s e d on a n s w e r s to the q u e s t i o n : " M r . B r o w n is a 7 0 - y e a r - o l d w i d o w e r . He worked hard all h i s life, until he had to retire, but w i t h the d e p r e s s i o n and r a i s i n g a f a m i l y , i t ' s been d i f f i c u l t to s a v e v e r y m u c h . N o w it l o o k s a s t h o u g h Mr. B r o w n is g o i n g to need regular money h e l p . Mr. B r o w n h a s two s o n s and a d a u g h t e r , all married, and w i t h small c h i l d r e n of their own. A l l of them are m a n a g i n g a l l right, but w i t h the w a y t h i n g s are now, they feel t h e y are j u s t getting a l o n g . Who d o y o u think Mr. B r o w n s h o u l d a s k to help h i m — a welfare a g e n c y , the government, or h i s c h i l d r e n , or someone e l s e ? (Why d o y o u feel this w a y ? ) "

135

The Health of Older People dividuals also thought Mr. Brown should ask the government or a welfare agency for help, individuals in this group were the most likely to say that he should turn to his children for help. Table 84 gives the replies of respondents in the subsample to the Mr. Brown question. Here the difference between the replies of older people with children and of their responsible individuals is clear-cut. Fewer than three of every ten older people with sons and daughters felt that Mr. Brown should ask his children for help. On the other hand, more than four of every ten children of these same older people said that Mr. Brown should turn to his children. Aged parents pointed out to the interviewers that Mr. Brown's children could not or were not able to help him. Further, some of them said, "It's a government's responsibility," or "This is the sort of thing the government does." The adult children of these older people, however, seemed to feel that it was a son or daughter's responsibility to help an older parent financially if it was at all possible. The answers to both the direct question "Who should take care of older people" and the indirect question about Mr. Brown suggest that older people in the United States want to be financially independent of their children. If the older person has been unable to save enough to make financial independence possible, then the majority of older people and of the public feel that the government, through income-maintenance programs, should assume the financial responsibility for his care. On the other hand, the sons, daughters, and other relatives of older people are less likely to say that this is a government responsibility. About two of every five children of the elderly feel that "it's a child's duty" to support his aged parents. This idea was explicitly stated by the twenty-six-year-old married son of a sixty-eight-year-old man. Parents care for their children, often having to go without things they need in order to do it. So I feel if in later years the story is reversed the children owe it to their parents to care for them if it is within their power. And I mean that if it is necessary to go without things they (the children) need in order to do it then they should be willing to sacrifice that much to make the old people happy and comfortable in their old age. Support for Parents Versus Other Demands

While many of the sons and daughters of older people appear to feel that children should support older parents in need, these feel-

136

>».· η " TJ « — 1 i-5 ο in Z i ο ο. c

Ο Ο ο

J 3 J £ Ο; ON β ι—- ·—• ΟΟ λ *· 0 ιη ci

tit'

1 =i -Ο -Ο » «. Χ β Ο g · - "3 - c c

*> •5 ϊ

C ο α Μ ο α

ο

Ο

»o LO Ο NO

I s i ε ο 7ο w» - ϋ5 Ζ JL

^

;

J

°

- ®

'i ° Ε 1 »«ι δ - c Ε-' Ο • ο ο

•>» CS •«» · · · m ·>» ·νβ — α. ο ο > S. S ϊ £ ο ΐ -ΐ α ö S £

ί-Ε-S

Ο ο Ο

Ο^ Ό *0 οά ή fx ^ CM «Ο «

υ

t j -c ϊ j : » ο κι "£ ϊ c ί

»X ν « Ο I ο ο «β> Μb

ο ί10 . U

•ί •-

ζ χ χ ϋ *•

Ο «

S * >

£

? ! σι β S 0 £ V _I ου .«η "σϊ 3 -·- « Ο c . β ϊ * — 'Ζ ο» * 0 οϋ u= 3s ·£ -C Ο r C * ® ι- .Ξ (ν.

l ^ i s S .2 «ι σι ο — « " J S

β

· 5

ο Ε "5 β Ε -C ο 5Ο Μ» mο 4- Μ. 0 Ο I» >. ι. C ϊ ο : ο -Ε

?ο

σι

CO —

? ι i . o w ο" £

6 · C β β ΜJ fc- l. JE t Β 5 D — Ο Ο Χ φ Ο Iυ » Ζ -

ί ϊ

»

ο ε £ -α 2 2 οc —

C • 50 ° c c Τ! ο » ®— * «1 U Ο Ο II ' CO β CO D ο. . - g i

w (J ΟΜ .. w ·= σι-ε c ι_ ο Χ ^ >· C l l

The Health of Older People ings do not always dictate actual behavior. Circumstances may make financial support to aged parents impossible. In addition, the son or daughter may feel that other needs are more important than a parent's need for financial support. Respondents were asked the following question about what a man should do when he had to choose between helping support his parents and purchasing a car for transportation to work. John and Alice Clark have been helping support John's father and mother, who live up the street from them. John works in the country, and unless he wants to spend four hours a day traveling, he has to drive to work. He's been having a lot of trouble with his car, and it looks as though he'll have to buy another one that's in pretty good condition. John's budget is so tight now that if he buys a car, the payments will make it impossible for him to help his parents. Then they'd have to get help from a welfare agency or the government. What should John do? As Tables 85 and 86 show, three of every four older people and three of every four responsible individuals felt that John should purchase the car in preference to continuing to support his parents. Mr. Stone, aged seventy-two and the father of three grown children, expressed the view of most older people when he said, " A man can't sacrifice his job altogether. The parents should get help from welT A B L E 85. Parental support v e r s u s a c a r — C h o i c e s esponsible individuals0

of older people and of

Percentage distribution Older people ••What should

John

do?"

All responsible individuals

Total

With living children

With no living children

Total

100.0

100.0

100.0

100.0

B u y ear H e l p parents B u y car and h e l p parents No answer Ν =

73.6 12.3 3.3 10.7 1,734

73.8 12.1 3.6 10.5 1,350

73.2 13.0 2.3 11.5 384

72.8 14.4 8.0 4.8 1,405

α B a s e d on a n s w e r s t o the q u e s t i o n : " J o h n a n d A l i c e C l a r k h a v e been h e l p ing s u p p o r t J o h n ' s father a n d mother, w h o l i v e up the street from them. J o h n w o r k s in the country, and u n l e s s he w a n t s to s p e n d four h o u r s a d a y t r a v e l l i n g , he h a s to drive to w o r k . H e ' s been h a v i n g a lot of trouble w i t h h i s car, a n d it l o o k s a s t h o u g h h e ' l l h a v e to buy another o n e t h a t ' s in pretty g o o d c o n d i t i o n . J o h n ' s budget i s s o tight n o w that If he b u y s a car, the p a y m e n t s w i l l make it i m p o s s i b l e for him to h e l p h i s p a r e n t s . T h e n t h e y ' d h a v e to g e t h e l p from a welfare a g e n c y or the g o v e r n m e n t . What s h o u l d J o h n d o ? "

138

τβ ο w j:ϊ k• · ~ Vα ι ο««• S Ο 00 ^ Ο ΙΟ α· L. η — Μ-cV +• β • ο«ι 5* « »i α »u ί-2 - Ι 3 i 2 β." > · 5 -Χ 1 3 ο . «Χ οηΝ» Χ> ΐν •C % "S 2οχΐ - 5s ® V ) ·· ·-· - 2 -5 • E £ *·? k >ο ^η a0 Χ ο χβ ο* -> ο 1Ε ·> » 1 g5 •β ΐ ΐ C-O TJ -Ο 1

ο

OL

2

ΐr οβυ *Χ O-C ο c "•«Oft « J- » x χ a· ΟC J —, — βkW k β ο. «ο u ν „ν α> ο ο. k w α 3 «ι ο ιλΓ ^ ο η >. ο JÜ ^ fsj CN (-Γ 00 ο · Jr ο- c φ -.!··£ •Ε' S 0 Sc ti i Ο Ο β* >. ο >-D Ο C J1 , χ ft .· Q. 0 jj JK « «- — oo · 5 U . j i ΐ - ί - ο —

Ο CS ·» CO • ο —

3 Ο » >>

χ Ε χο > ο α.

ΐ >= » — -C ε "5 t :> ϊ * c > —flffl flj *0 3 .Ε ο — α vi ο _ (Α Ο®

C _ Ol β ΐ .Ε-σ ϊϊ·:

— *ft · β~ 1 β. hj ΙΟ «Ο ΙΟ g cΟ η« ο Ei. ^ Μ (ΊΟ ο Ζ. ΡΓ». Ε—ο χ c — "*> » ' ! > χ= ~»-ο Ζ C Μ «ι Ο ο ο ί: c -1 c .2 kC —ο Ε·2 ^ » 1 - S2

υ

• -c 1 •£ «- ο t-S " » · » « υ* = ΐ«ι ί ·- ° ΕΕ

03 < Ι-

i ϊ

η _Τ «C • C Ο kft k s k * β υ S. υ" c« 1 Χ ) 3 · 3. ·Ο αχοζ

Cf / ο c-> -§-= ft ο τ ι ι. • ·

CO

0

Sο •ϊ ο

'S

0

- « * 01 · ο C ο

The Health of Older People fare." Mr. Lewis, aged sixty-seven and the father of five children expressed the point of view of the minority: "He sure lives a long way from his job. I don't hardly know what to say. Well, I'd say he ought to help his parents and try to make some other arrangement about getting to work, like a car pool or something." The majority of sons, daughters, and other relatives, like the majority of older people, felt that John had to have the car to continue working. Eunice Rcy, the major support of her aged mother, was typical of three of every four responsible individuals when she said, "I think John should ask a welfare agency for help (for his parents) because he has to have a car or he would lose his job." On the other hand, a minority of responsible individuals felt that somehow John should work out some way to continue to support his aged parents. Marjorie Summers, the twenty-nine-year-old daughter of a sixty-sixyear-old man, offered this solution to John's problems: "Couldn't the parents live with him? It would be cheaper and maybe they could pool their resources." Summary

Older people still play a major part in family life in the United States. The three-generation family may no longer occupy a single house, but older people who have children live near at least one of them, and the affectional and other ties which bind families together seem to be strong and flourishing. Older people without children try to maintain family relationships with other relatives, particularly with their brothers and sisters. Only a very small group of the aged appear to be truly isolated. In case of illness, older people with sons and daughters would turn to them for help. Daughters and daughters-in-law would be asked for help more often than sons. When illness causes a change in living arrangements, older people and their sons and daughters alike try to keep the older person in his own home. If this is not possible, then the older person is moved into the son's or daughter's home. Both old people and their children view this as an inevitable but not desirable development. Older people without children turn to their relatives for help when they are ill. When they have no close relatives, they ask neighbors, friends, or distant relatives to help, in preference to social workers, ministers, or doctors. Every effort is made to avoid institutionalization. 140

Older People and Their Families A majority of older people and of the public believe that adult sons and daughters must assume certain responsibilities toward their aged parents. These responsibilities of children to parents are largely in the area of interpersonal relationships. Most persons, whether old or young, feel that sons and daughters should be willing to make adjustments in their mode of life when self-interest conflicts with the needs and interests of aging parents. While a substantial group among the sons and daughters of older people share this point of view, a majority do not always agree that "parents come first." Apparently, the children of older people are strongly motivated to maintain good relationships with their parents if it is at all possible, but the demands and needs of their own families sometimes conflict with and override their parents' demands and needs. Older people want to be financially independent. A majority of them feel that if an older person has been unable to save enough to make this independence possible in later life the government should assume responsibility for his support through various income maintenance programs. The sons, daughters, and other relatives of older people are less likely, however, to say that the government should support the elderly. A substantial group of sons and daughters (about two of every five) feel that the support of older people is their children's duty. What older people seem to want most from their children is love and affection. Many older people apparently feel that to ask their children for financial help would threaten the affectional relationship between the generations.

141

VII The Health of Older People: The Reports of Responsible Individuals So much attention has been given to the needs of the sick in the older population that it is sometimes forgotten that most older people consider themselves well. Only one of every five older people interviewed in this survey thought that his health was "poor." Four of every five thought that their health was "good" or "fair." However, the popular conception of the aged as "sick" appears in most discussions of the aged—particularly of the indigent aged. Sometimes, in fact, the words "sick" and "indigent" seem to be used as synonyms to describe the older population in the United States. It is true that a substantial number of older people have incomes far lower than those of most other Americans. But not all of these people in the lowest income brackets are sick, and not all sick older people are indigent. This study indicates that, contrary to general belief, most older people in the United States are meeting the costs of routine or occasional medical services through their own resources. Reports by older people contradict the common belief that most of their medical bills are paid for them by their children, by other relatives, or by public welfare authorities and private charities. Do thesefindingsgive a "true" picture of older people living outside of institutions? Or can it be that the sample of older people interviewed concealed the truth about their health situation and their usual medical expenditures? These questions give rise to a third, equally important: is it possible that many widely held beliefs about older people stem from public experience with that minority among the aged who are "problems," "sick," "infirm," and "indigent?"

142

Reports of Responsible Individuals This chapter compares these reports of older people on health and medical care with the reports of the persons older people named as the individuals they would turn to in case of illness—the next-ofkin and close friends of the elderly. These next-of-kin were interviewed about the specific older person they knew well. Their reports therefore summarize the experience of people who are concerned about and have a close acquaintance with at least one person sixtyfive or older. Most of the people the aged had named as those they would turn to in a health crisis were intimately acquainted with the older people. When an older person had adult sons and daughters, in nine cases of every ten the individual he named was one of them; when an older person had no children, the individual he named was usually a relative. As a result, these people usually were familiar with the older person's living arrangements, health status, and finances. Evaluation of the Health of Older People

The average responsible individual saw the older person about whom he was interviewed at least once a week. Half saw the older respondent every day. The majority described the older person they knew as in "good" or "fair" health. Fully half termed the older respondent's health "good" (Table 87). Mrs. Green, for example, a grandmother in her fifties, thought that her eighty-three-year-old mother's health was good. "She just has neuritis in her head when she takes a cold." Mrs. Sorenson, similarly, thought her seventy-two-year-old mother was in good health. "She's pretty active around the house and garden." Sometimes, the older person whose health was described as "good" had a history of illness. Mrs. Morrison said that her seventyyear-old sister, Mrs. Cornell, was in good health and told the interviewer, "Considering all she has been through, I think it's very good. She had a coronary thrombosis four or five years ago. It happened in the street . . . She sat in her car for a half hour trying to attract a passerby's interest." Mrs. Morrison said that Mrs. Cornell's health was now "above average, better than the health of most older people." In fact, Mrs. Morrison complained to the interviewer that although Mrs. Cornell had been advised to restrict some of her activities, she would not do so. "She just goes up and down stairs . . ." Apparently, those to whom the elderly would turn in a health cri-

143

The Health of Older People T A B L E 87. A s s e s s m e n t o f h e a l t h by o l d e r p e o p l e and by t h o s e to whom they w o u l d turn in a health c r i s i s Percentage distribution Assessment

Older p e o p l e for whom responsible individuals were i n t e r v i e w e d

Responsible individuals

H e a l t h at p r e s e n t time 100.0

100.0

51.4 28.8 19.8 0.1

53.2 30.3 16.0 0.5

Total

100.0

100.0

Better A b o u t the s a m e Worse Other and N o a n s w e r Ν =

50.1 34.8 13.6 1.5 1,405

49.6 37.9 11.7 0.8 1,405

Total Good Fair Poor Other and N o a n s w e r H e a l t h compared with that of other older p e o p l e

sis saw these older people very much as the elderly saw themselves. The great majority of older people in the United States believe they are in good or fair health. Dr. Robert T. Monroe has commented on this belief: "Old people have more than the young to be sick with and sick of, yet they call themselves well if they view their balance as satisfactory and sick when they find it less so." 1 In most instances, if the older person considered himself well, the individual he would turn to in a health crisis also thought the older person was well. Again and again, these individuals told interviewers that if proper allowance were made for age, their older relative or friend was in excellent physical condition. Although responsible individuals reported that the older person they knew was in good or fair health, they did not consider that person typical of all older people. Half said that the health of the older person they knew or were related to was better than the health of other older people. Two thirds said that the older person about whom they were interviewed saw a doctor less often than most persons his age. It has been demonstrated that the "very sick" in the older popu1 Robert T. Monroe, "How Well Are Older People?" The Journal of the Michigan State Medical Society, Vol. 59 (May I 9 6 0 ) , p. 751.

144

Reports of Responsible

Individuals

lation are the heaviest users of medical care. Even the individuals responsible for these "very sick," however, believed that their particular older relative or friend was less sick than others in his age group. To illustrate, two of every five of these responsible individuals named by the "very sick" felt that their older respondent saw a doctor less often than other old people. In other words, responsible individuals shared the common belief that the majority of older people are sick. But their attitude toward their own—toward the person to whom they were close— seemed to be: "My mother is doing pretty good, but other people's mothers are probably not as well as she is." Although an older person and his responsible individual were likely to agree on the older person's state of health, the current illness rate reported for themselves by older people was substantially higher than that reported for them by relatives or friends. Seventeen of every twenty older persons interviewed in the subsample (the same proportion as in the nationwide sample of older people) said that they had had some illness or health complaint during the four weeks preceding the interview. When responsible individuals were interviewed concerning these same older people and asked, "Does

the older person have any sickness, any health problems, or maybe

an old injury that bothers him now?" only twelve of every twenty said that their elderly relative or friend was "bothered" by an illness or health problem. The differences in these answers concerning the current illness rate result chiefly from the definition of "illness" held by the responsible individuals.

A substantial number of older people reported that their illnesses during the four weeks preceding the interview consisted solely of complaints such as headaches, shortness of breath, and constipation. It was the individuals responsible for these persons who were likely to have said "no" to the question of whether the older persons had "any sickness, or any health problems . . ." It is possible that the specific health complaints of the older person may not have been known to his next-of-kin or friend. On the other hand, the responsible individual simply may not have considered such health complaints as illness. Responsible individuals also were less likely than older persons to report that an older person had certain kinds of impairments and disabilities such as hearing loss and loss of vision, unless these conditions were quite severe. Difficulties in walking, often reported by 145

The Health of Older People the older person, were less likely to be reported by responsible individuals. Whether or not responsible individuals reported that an older person had impairments or disabilities seemed to be related to the degree of the impairment. Underreported disabilities were those that did not usually affect the over-all functioning of older people. It is only when hearing loss approached total deafness, for example, or vision loss approached blindness, or walking difficulties approached immobility, that responsible individuals reported them as impairments of the elderly. In general, the common view that older people have of themselves—that they are well and not sick—was shared by the individuals responsible for them. Older persons might report a greater number of specific complaints than their responsible individuals would, but, over-all, older people and those who would be called on for help in an extended illness had the same ideas about what constituted sickness in later life. A long-time chronic condition, unless seriously disabling, was not considered an illness. Impairments and disabilities, unless incapacitating to the older person, were not considered serious complaints in an evaluation of the health of the older respondent. Most responsible individuals, as most of the elderly, agreed that "older people have to expect a lot of aches and pains." Since aches and pains are considered normal in later life, responsible individuals did not include such aches and pains among their criteria for sickness or wellness. Like older people themselves, their relatives and friends look on the elderly as being sick only when there is an acute illness episode or a catastrophic, long-term illness. Utilization of Medical Care

Older people and their closest relatives or friends, interviewed separately, agreed on whether or not the older person had a serious health problem. When an older person had spent considerable time in bed because of illness or had had nursing care or extended medical services, he and the individual responsible for him both reported these incidents. Reports on the amount of time the elderly had spent in bed because of illness are given in Table 88. About eight older persons in a hundred said that they had been confined to bed for a month or more during the year before they were interviewed, one person in every hundred reporting that he had spent all of this time in bed. 146

Reports of Responsible

Individuals

T A B L E 88. T i m e spent in bed b e c a u s e of i l l n e s s during 12 m o n t h s before the i n t e r v i e w — R e p o r t s of older p e o p l e a n d of t h o s e to whom they w o u l d turn in a health c r i s i s Percentage distribution T i m e s p e n t in bed during p a s t year

Older p e o p l e for whom responsible individuals were interviewed

Responsible individuals

Total

100.0

100.0

A l l the time T h r e e m o n t h s or more O n e to three m o n t h s O n e to four w e e k s L e s s than a week None N o a n s w e r or D o n ' t k n o w Ν =

1.0 2.6 4.1 10.0 14.8 67.3 0.1 1,405

0.7 2.9 4.3 12.2 16.8 59.4 3.8 1,405

Most older people (almost seventy of every hundred), however, said that they had not been confined to bed at all during the preceding year. Most individuals responsible for them (about sixty of every hundred) agreed that these same old people had spent no time in bed because of illness. Even though an occasional day in bed may be forgotten and not reported either by older people themselves or the individuals responsible for them, the replies of both groups indicate clearly that the bedridden aged are only a small fraction of the total older population.2 A majority of older people, contrary to popular belief, are rarely sick enough to be confined to their beds. They do have many illnesses, aches and pains, and health complaints. These, however, are not considered serious enough to require bed rest. Just as older people and their responsible individuals agreed on the amounts of time the older people had spent in bed, the two groups agreed on the amount of nursing care the elderly had required. Both groups reported that about seven older people in a hundred had had nursing care at home during the four weeks preceding the interview, and that children and relatives gave most of this nursing care. 2 It should be recalled that a small group of the "very sick" in the older population could not be interviewed. But even if the extreme assumption were made that all older people who were located but not interviewed (because they were "too sick," "too deaf," refused the interview, and so on) spent a day or more in bed due to illness during the survey year, half of all older people located would still have spent no time in bed because of illness.

147

The Health of Older

People

Older persons with current health problems were naturally more likely than other older people to have had some recent contact with a physician. In all, three of every ten older respondents in the subsample (the same proportion as in the nationwide sample) had seen a physician or talked to him on the telephone during the four weeks preceding the interview. However, older people whose responsible individuals had answered "yes" to the question "Does the older person have any sickness, any health problem, or maybe an old injury that bothers him now?" were two and one half times as likely as other older people to have had some contact with a physician.3 Why those older people whose close relatives or friends thought they were sick were more likely than other people to see a doctor is only suggsted by the data. Perhaps the relative or friend, deciding that the older person was "sick," insisted he see a doctor. It seems equally likely that, since older people and the people they would turn to in illness hold the same conception of illness, the older people themselves decided to consult a doctor. It seems unlikely that responsible individuals thought older people were sick because they had seen a doctor. This would not accord with the general attitudes toward medical care these people expressed in their interviews. Ordinarily, the older person or his close relative or friend first decides that the older person is sick. Then, the older person sees or telephones a physician. Two thirds of all responsible individuals felt that the older person about whom they were interviewed saw a doctor about as often as he should. The remaining third felt the older person was not seeing a doctor often enough. In general, those who had described their older relative's health as "good" or "fair" felt that they were seeing a doctor as often as they should. Half of those who had described their older relatives' health as "poor," however, felt that the older persons should see a doctor more often. Those who said their older relative was not seeing a doctor often enough were asked why. Why, in the opinion of persons who knew them well, were about one third of all older people not using medical care as often as they should? The replies agreed closely with what older people themselves had said when they were asked why 3 Thirty-nine per cent of all older people whose responsible individuals answered "yes" to this question, compared with 15 per cent of all older people whose responsible individuals answered "no," had seen or telephoned a doctor.

148

Reports of Responsible

Individuals

they did not consult a doctor about illness—that they would not see a doctor unless an illness was serious. As one young man said, describing his father: "He doesn't believe in doctoring." The same kind of answer was given by older people themselves, since usually when they were asked why they had not seen a doctor for a reported illness, they answered that they were not sick enough; there was no need to consult a doctor because they could treat their illness as well as the doctor could. Lack of money was mentioned as a deterrent to the aged in seeking medical care by five of every one hundred responsible individuals in the subsample, compared with eight of every one hundred older people themselves. Income sources and levels of income differed among these older persons whose responsible individuals felt that they were not seeing a doctor because of lack of money. Some were public assistance recipients; others had small money incomes from other sources. Still others seemed to be in better economic circumstances but were reported as feeling that medical care was "too expensive." Among public assistance recipients whose close relatives or friends believed they should see the doctor more often, Mattie Kent and LeRoy Smith were typical. Mrs. Kent's neighbor thought that Mrs. Kent should see the doctor more often "Because she complains from an operation. She does not have the money to pay for seeing a doctor." Mr. Smith's son felt that his father should see the doctor more often. He said that his father saw the doctor every three or four weeks, but he (the son) did not feel that this was often enough. The reason his father did not see the doctor more often was "more or less financial. He's in pretty bad financial shape." Alice Curtis was representative of those older people, not receiving public assistance, who were just making ends meet, and whose relatives or friends felt that they should see the doctor more often. Mrs. Curtis and her husband live on a farm. Their son John, who has been supplementing his parents' income and paying some of his mother's medical bills, said that she had pernicious anemia. He felt that his mother does not see a doctor as often as she should because "she worries about the money. If she feels they haven't the money for the doctor she doesn't go when she should for her three-months' visit." Mrs. Kent, Mr. Smith, and Mrs. Curtis were all older persons

149

The Health of Older People with very low money incomes. A few older people who were reported as not seeing a doctor because they lacked money, however, were apparently in the middle-income group. Grace Wills, for example said that her seventy-two-year-old mother, Mrs. Ross, would not see a doctor because she did not have enough money. Mrs. Ross was typical of those middle-income older people who felt that medical care was "too expensive," although she owned two houses, one of which yielded rental income; she received some money from Social Security payments; and she had savings. Grace Wills said that her mother had diabetes. She felt that her mother should see the doctor more often but "She says she needs the money. The doctor said he ought to see her more often on account of the sugar tests. She says it costs too much." The reports of their close relatives and friends do not indicate that most older people in the United States do without routine medical care because of lack of money. While these individuals say that thirty-three of every hundred older people should see a doctor more often, they believe that only five of every hundred persons are not seeing a doctor as often as they should because they lack the money for medical care. Much more often, they report, the attitudes of older people themselves—their beliefs that they are not sick enough to see a doctor—are the chief obstacles to their seeking medical care. Some older persons reported as not seeking medical care because they do not think they are sick, of course, might think differently if their incomes were larger and if they felt they could afford expenditures for medical care. However, even if this were true for all persons reported as not seeing a doctor often enough (an unlikely supposition), two thirds of all relatives and friends still think that the older persons they know are receiving an adequate amount of medical care. Meeting the Costs of Medical Care

The close relatives and friends of older people were asked, "Who usually pays the older person's doctor bills? Is he able to pay them himself, do his children or other relatives pay them, or does he usually get free care?" They reported that 80 per cent of all older people usually paid their doctor bills out of their own income or savings (Table 89). Sons, daughters, or other relatives paid doctor bills for about 12 per cent, and welfare or charitable organizations paid these 150

Reports of Responsible

Individuals

T A B L E 89. Who usually paid t h · physician bills of older people—Reports of responsible individuals of the very sick and of responsible individuals of all other older people" Per cent reporting thi s source

b

Source of payment

Total

Responsible for very sick

Responsible for all others

Older person or spouse Children or relatives Welfare or charitable organization Veteran's Administration Insurance No answer or Don't know

80.1 12.3 5.3 0.5 2.4 4.5 1,405

66.5 21.3 16.1 1.3 1.9 3.9 155

81.8 11.2 3.9 0.4 2.5 4.6 1,250

Ν=

"Based on answers to the question: "Who usually pays older person's doc· tor bills? Is he able to pay them himself, do his children or other relatives pay for them, or does he usually get free care?" ^These per cents do not total 100 since the responsible individual may have reported several sources from which the older person made physician payments.

bills for about 5 per cent. The small number of "very sick" older people in the subsample were reported as being twice as likely as other older people to have had their doctor bills paid by sons, daughters, and other relatives, and three times as likely to have had these bills paid by welfare and charitable organizations. The reports of close relatives and friends on how older people usually paid their physicians' bills agreed with what older people themselves had said—that the majority of older people paid current doctor bills from their own resources. Seven of every ten older people had said that they were paying their current physician bills themselves.4 Responsible individuals reported that eight of every ten older people usually paid their medical bills out of their current income and savings. In some instances, the close relatives and friends reported that older people whose main source of income was public assistance were paying their medical bills from current income. Although only a small minority of either older people or the individuals responsible for them said that sons, daughters, or other relatives paid current medical bills for the aged, there was some discrepancy between the reports of the two groups. Twice as many close relatives and friends as older people themselves reported these payments by sons, daughters, and other relatives (12 per cent compared with 6 per cent). * See Table 56.

151

The Health of Older People As noted in an earlier chapter, when older people are hospitalized their average stay is longer and usually more expensive than the hospital stay of younger persons. Because so many older people have low money incomes, it would be expected that adult sons and daughters, other relatives, and welfare and charitable organizations would be called upon to meet the costs of hospitalization for the elderly more often than they would be asked to pay current bills for physicians' services. Eleven per cent of all older people in the subsample were reported by their responsible individuals as having been hospitalized during the survey year.5 Most of these persons (64 per cent) were reported to have paid the costs of their own hospitalization, using current income, savings, or hospital insurance (Table 90). Sons, daughters, and other relatives were reported to have paid all or part of the costs of hospitalization for 15 per cent of the older people who were hospitalized; welfare and charitable organizations were reported to have absorbed some or all the costs of hospitalization for 14 per cent. As expected, the proportion of hospitalized older people whose bills were paid by sons, daughters, or relatives or by welfare and charitable organizations was higher than the proportion of persons whose current doctor bills were paid by these sources. About one person in five was reported to have had his current doctor bills paid by his children and relatives, or by welfare and charitable organizations. Among older people who were hospitalized, however, one in three had the cost of hospitalization met by sons, daughters, or other relatives, or by welfare and charitable agencies. Some older persons who previously had been reported as paying their own current doctor bills were now reported to have had their hospital costs paid by their relatives or by a welfare agency. These reports of how older people met the costs of recent hospitalization were in substantial agreement with the reports of the older people themselves—that most older people paid hospital bills from their own resources.6 There is no indication from the reports of either group that most older people received free hospital care or that their hosiptal bills were paid by family members. Of course, hospitalization may be only one incident in a long5

In the nationwide sample 10.4 per cent of all older people had reported that they had been in the hospital during the preceding year. 6 The reports of older people were given in Table 57.

152

Reports of Responsible

Individuals

T A B L E 9 0 . How older people paid hospital c h a r g e s — R e p o r t s of responsible individuals of older people hospitalized during the survey year Percentage distribution

Source of payment Total

100.0

B i l l paid completely by: Income or savings Insurance C h i l d r e n or r e l a t i v e s Borrowed money Welfare or charitable organization V e t e r a n s ' Administration

30.1 16.0 10.9 0.6 12.2 1.9

B i l l paid by combination of: Income or savings and insurance . Children and insurance Children and savings Income and borrowed money Welfare or charitable organization and children or relatives No answer or D o n ' t know Ν =

17.4 1.9 1.3 0.6 1.3 5.8 156

term illness. Older people may have extensive medical care at home interrupted by periods in a hospital. To obtain some idea of how all older people had met the costs of recent major illness whether in or not in a hospital, their responsible individuals were asked, "Has the older person had any serious sickness in the last few years? How did he take care of the bills? Was he able to pay for them, did children or relatives help, or was he able to get free care?" Almost one older person in every four (23 per cent) was reported to have had a serious illness during the past few years. The proportion of older people with reported serious illness was twice the proportion that had been hospitalized during the previous year. Most of those with serious illness (72 per cent) were reported to have paid all or part of the bills from their illness from their own resources: income, savings, or health insurance (Table 91). For the remaining one older person in three who had a serious illness, some or all of the costs of the illness were absorbed by relatives or by some form of free care. The answers of the persons to whom older people would turn in illness to this series of questions on how older people met the costs of their usual medical care, of their recent hospitalizations, and of recent serious illness all indicate that in at least two thirds of the cases these costs were met by older people largely through their own 153

The Health of Older People T A B L E 91· How older people w h o had s e r i o u s i l l n e s s e s in recent y e a r s paid the c o s t s for the i l l n e s s — R e p o r t s of r e s p o n s i b l e i n d i v i d u a l s of the very s i c k and of r e s p o n s i b l e i n d i v i d u a l s of all other older p e o p l e · 0

Per cent reporting t h i s s o u r c e ' ' S o u r c e of payment

Income or s a v i n g s Insurance C h i l d r e n or r e l a t i v e s Borrowed money Welfare or c h a r i t a b l e o r g a n i z a t i o n N o fee c h a r g e d N o a n s w e r or D o n ' t know Ν =

R e s p o n s i b l e for very s i c k 67.0 12.2 20.2 0.3 8.9 4.3 6.4 327

60.8 12.2 24.3 1.4 16.2 5.4 4.1 74

R e s p o n s i b l e for all others 68.8 12.3 19.0 — 6.7 4.0 7.1 253

" B a s e d on a n s w e r s to the question: " H a s the older p e r s o n had any s e r i o u s i l l n e s s in l a s t few y e a r s (other t h a n the h o s p i t a l i z a t i o n y o u told me a b o u t ) ? How did the older p e r s o n take care of the b i l l s ? Was he able to pay for them h i m s e l f , did h i s c h i l d r e n or other r e l a t i v e s h e l p him, or w a s he able to get free c a r e ? ( J u s t how w a s t h i s h a n d l e d ? ) " bPer c e n t s do not total 100 s i n c e e a c h older p e r s o n may have paid medical b i l l s from s e v e r a l s o u r c e s .

resources. The usual or routine medical bills of the elderly were the most likely of all medical costs to be met by older people themselves. As the medical bills became larger, either as a result of hospitalization or because of serious illness, about one third of all older persons incurring them were forced to call on their sons, daughters, or other relatives or on some form of free care for assistance. While only a minority of older people were reported to have been hospitalized during the survey year or to have had a recent serious illness, any of the older age group could develop a major illness or require hospitalization in the future. To determine how their close relatives thought older people would meet the costs of a major illness now, these individuals were asked, "What if the older person had a serious sickness now? Suppose he had a large medical bill— say $500—how would he manage it?" In their answers to this question responsible individuals showed familiarity with the financial status of the older person. Some mentioned only a single source of funds from which the older person might be expected to pay a medical bill as large as $500; others named several sources of funds. The detailed answers to this question, which are similar to the replies of older people themselves to a comparable question, are shown in Table 9 2 / 7

The reports of older people were given in Chapter IV.

154

Reports of Responsible

Individuals

T A B L E 92· S o u r c e s of f u n d s older p e o p l e w o u l d u s e to pay a $ 5 0 0 medical B i l l — R e p o r t s of r e s p o n s i b l e i n d i v i d u a l s of p e r s o n s a g e d 65 y e a r s a n d over S o u r c e of f u n d s

P e r cent reporting this source

Total

100.0

Single source only Savings Current income Life insurance M o r t g a g e on h o u s e or property C h i l d r e n or r e l a t i v e s P u b l i c a s s i s t a n c e or c h a r i t a b l e a i d H o s p i t a l or h e a l t h i n s u r a n c e

55.2 15.2 9.7 0.1 1,3 15.2 5.7 7.7

T w o or more s o u r c e s S a v i n g s a n d other s o u r c e s Income a n d other s o u r c e s L i f e i n s u r a n c e a n d other s o u r c e s M o r t g a g e on h o u s e or property and other s o u r c e s C h i l d r e n or r e l a t i v e s a n d other s o u r c e s P u b l i c a s s i s t a n c e or c h a r i t a b l e a i d a n d other s o u r c e s H o s p i t a l or h e a l t h i n s u r a n c e a n d other s o u r c e s

35.2° 20.3 14.8 0.2 1.7 15.7 3.0 16.6

C o u l d not p a y s u c h a b i l l

2.6

N o a n s w e r or D o n ' t k n o w N =

7.0 1,405

a P e r c e n t s l i s t e d under " T w o or more s o u r c e s " do not total 35.2 per cent s i n c e the s a m e s o u r c e may be reported in s e v e r a l c a t e g o r i e s . F o r e x a m p l e , s a v i n g s a n d h e a l t h i n s u r a n c e are reported both under " S a v i n g s and other s o u r c e s " and " H o s p i t a l or health i n s u r a n c e and other s o u r c e s . "

Most people assumed in answering this question that a serious illness for the elderly would necessarily include a stay in a hospital. One of every four (24 per cent) reported that the older person he knew would meet the costs of the serious illness in whole or part through health or hospital insurance. More than half ( 5 4 per cent) said that their older relative or friend would meet the bill from income or savings, supplemented in some instances by health or hospital insurance or by help from sons or daughters or other relatives. Almost a third (31 per cent) said that sons, daughters, or other relatives would have to pay part or all of the bill. Fifteen per cent said that relatives would have to pay all the bill. About one in ten (9 per cent) said that the older person would have to call on public assistance or charitable aid to meet a bill of $500; three in a hundred said that the older person simply could not pay such a bill. To summarize the replies of these relatives and friends, in their opinion, about five of every ten older persons could meet a $500

155

The Health of Older People medical bill largely from their own resources, current income, savings, and health and hospital insurance; about three of every ten older persons would have to have such a bill paid, in whole or part, by their sons, daughters, or other relatives; at least one of every ten older persons would have to turn to public assistance or charitable agencies. Two fifths of all older people, therefore, could pay a medical bill of $500 only with the help of their families or of charitable agencies. The individuals to whom older people would turn in a health crisis were asked to make an over-all assessment of the financial status of the older person: "In order to help people get the best possible medical care, we have to know something about how they're getting along in the way of money. How would you say the older person is getting along financially, compared with when he was 60?" A majority of responsible individuals felt that the financial situation of the older person they knew was as good or better in 1957 than it had been when he was 60. Forty-seven per cent of all older people were described as managing as well financially as when they were 60; 15 per cent were described as being in a better financial position, and 32 per cent were reported to be in a worse financial state.8 In general, relatives and friends who were interviewed believed that most older people had enough money to meet their usual needs. They were asked: "Would you know if there is anything special the older person has had to do without because of not having enough money?" Four of every five said that the older person had no unmet needs. Only one older person in five was said to be doing without some necessity because of lack of money (Table 93). Answers to this direct question about limited finances affecting the needs of older people supported earlier statements by their close relatives that five older people in every hundred were not seeing a doctor because of lack of money. Specifically, only seven older people in a hundred were said to be without medical or dental care because they lacked funds. The great majority of responsible individuals, like the great majority of older people themselves, apparently did not feel that their limited funds deprived older people of medical or dental care. The reports of their close relatives and friends indicated that older people faced at least two different levels of medical bills: bills for oc8

These data may be compared with the replies of older people to this same question in Table 55.

156

Reports of Responsible

Individuals

T A B L E 93» P r o p o r t i o n of older p e o p l e w i t h unmet n e e d s due to lack of m o n e y — R e p o r t s of older p e o p l e a n d t h o s e to whom they w o u l d turn in a h e a l t h crisis® Percentage distribution

Unmet need of older p e r s o n

Older p e o p l e for whom responsible i n d i v i d u a l s were interviewed

Responsible individuals

Total

100.0

100.0

M e d i c a l or d e n t a l c a r e Other i t e m s Nothing N o a n s w e r or D o n ' t k n o w

8.6 13.2 77.5 0.6 1,405

6.7 5.8 83.8 3.7 1,405

Ν=

" B a s e d on a n s w e r s to the f o l l o w i n g q u e s t i o n s — O l d e r people: " A r e there a n y t h i n g s y o u e s p e c i a l l y need that y o u ' v e h a d to do without b e c a u s e y o u d o n ' t h a v e e n o u g h m o n e y ? " R e s p o n s i b l e i n d i v i d u a l : " W o u l d y o u k n o w if there i s a n y t h i n g s p e c i a l that the older p e r s o n h a s had to d o without, b e c a u s e of not h a v i n g e n o u g h m o n e y ? "

casional care, and bills associated with hospitalizations and severe illness. The great majority of older people paid routine or occasional medical bills from their own resources. Further, about two thirds of aÜ older persons who had been hospitalized or seriously ill paid their own bills. A medical bill as large as $500, however, would precipitate a serious financial crisis for many older people, and only about half could meet such a bill from their own resources. Opinions About Government Health Insurance

The younger people to whom the aged would turn in illness were asked their opinions about government health insurance. They were told: "Some people think that the government should provide insurance that pays doctor and hospital bills. Other people disagree with this idea. Are you in favor of government insurance that pays doctor and hospital bills, or against it?" Almost half of these persons said they favored government health insurance (Table 94). Those in favor of government health insurance were then asked if they thought everyone or just certain kinds of people should have such insurance. About half (22 per cent of all responsible individuals) thought that everyone should have government insurance; the remainder felt that it should be available primarily for people of all ages who could not afford voluntary health insurance. 157

The Health of Older People T A B L E 94. Attitudes toward government health I n s u r a n c e — R e p o r t s of older people and those to whom they would turn In a health c r i s i s

Attitude toward government insurance

Older people for whom responsible individuals were interviewed

Total

Responsible individuals

100.0

100.0

In favor For everyone For all old people For those who cannot afford it For others

54.9 30.0 1.8

48.5 22.5 3.5

19.3 3.8

18.5 4.0

Against

41.3

48.9

3.8 1,405

2.6 1,405

No answer or Don't know N =

Older people and their close relatives and friends were not always in agreement about government health insurance. In about three of every five instances they agreed; in two of every five instances the older person held one opinion, the responsible individual another. In general, responsible individuals who were in favor of government health insurance were likely to have lower family incomes than those opposed to it (Table 95). They were also more likely to have reported that their older relatives were not getting along as well financially as they had at 60. Whether or not a responsible individual favored government health insurance was most clearly reflected in his over-all attitude toward the responsibilities of the federal government in the field of social welfare—his answer to the question "Who should take care of older people when they are no longer working?" 8 Among those who thought that the older person should provide for himself in old age, three of every ten were in favor of government health insurance; among those who thought that sons, daughters, or other relatives should take care of the elderly, almost five of every ten were in favor of government insurance; among those who thought that the government should take care of older people, six of every ten were in favor of government health insurance. 9

This same relationship was reported for older people in Chapter IV.

158

Reports of Responsible Individuals T A B L E 95· F a m i l y i n c o m e and a t t i t u d e s related to f i n a n c i a l support of older p e o p l e — R e p o r t s of all r e s p o n s i b l e i n d i v i d u a l s and t h o s e who favor g o v e r n ment h e a l t h i n s u r a n c e P e r cent of ,, ... all r e s p o n s i b l e indlv d I s

F a m i l y income and a t t i t u d e s L .Ι, ι ι .. about f i n a n c i a l s u p p o r t

P e r

eenf

of

s p e c i f i e d groue in , , favor of government health insurance

Family income (dollars) Total None Under 3 , 0 0 0 3,000-5,000 5,000-7,499 7 , 5 0 0 and o v e r No answer How

Is the older person getting financially compared with he was 60?

A b o u t the s a m e Better Worse C a n ' t compare N o a n s w e r or D o n ' t k n o w

0.3 28.7 29.0 21.3 14.6 6.1

° 60.8 49.8 45.2 32.7 34.9

100.0

48.5

47.3 15.3 31.8 4.7 0.9

45.3 39.5 57.9 47.0 ο

100.0

48.5

17.9 40.1 5.6

29.5 45.2 48.7

34.3 2.2 1,405

62.7 °

people working?

Total S h o u l d p r o v i d e for t h e m s e l v e s C h i l d r e n or r e l a t i v e s Employer pension plan G o v e r n m e n t through s o c i a l s e c u r i t y and other m e t h o d s Other and N o a n s w e r N = a

48.5

along when

Total

Who should take care of older when they are n o Ionger

100.0

P e r c e n t s not computed w h e n b a s e i s l e s s than 25.

Attitudes Toward Health and Doctors

Older people and their younger relatives had similar attitudes toward the health of the elderly. From their own personal experiences, both groups were optimistic in their health evaluations. About three of every four older people and three of every four of their responsible individuals agreed with the statement that, "The way things are now, most people can expect to feel pretty good when they're seventy" (Table 9 6 ) . However, for older people as well as for their rel-

159

The Health of Older People T A B L E 96. A t t i t u d e s toward h e a l t h and d o c t o r s — R e p o r t s and of t h o s e to whom they w o u l d t u m in ο h e a l t h c r i s i s

of older p e o p l e

Percentage distribution Older people for w h o m R e s p o n s ible responsible individuals individuals were i n t e r v i e w e d

Statement

A p e r s o n u n d e r s t a n d s h i s o w n health better than m o s t d o c t o r s do Older p e o p l e h a v e to e x p e c t a lot of a c h e s and p a i n s D o c t o r s g i v e y o u a s much time and attention a s y o u n e e d , whether y o u ' r e p a y i n g them or not D o c t o r s l i k e to t a k e care of y o u n g e r p e o p l e better than they do older p e o p l e T h e w a y t h i n g s are n o w , m o s t p e o p l e c a n e x pect to feel pretty g o o d w h e n t h e y ' r e s e v e n t y Ν =

63.5

42.5

77.7

67.2

47.5

43.6

41.1

27.0

75.3 1,405

72.2 1,405

atives or close friends, feeling "pretty good" at 70 apparently was not the same as feeling "pretty good" in the younger years. To feel "pretty good" at 70 meant that one accepted chronic illness and its accompanying discomforts. Both groups agreed that despite feeling "good," older people had to expect "a lot of aches and pains." Older people and their responsible individuals disagreed on certain aspects of the patient-doctor relationship as it affected older people. Older people were far more likely than their responsible relatives (64 per cent compared with 43 per cent) to agree that "A person understands his own health better than most doctors do." Similarly, older people were more likely than their responsible relatives (41 per cent compared with 27 per cent) to agree that "Doctors like to take care of younger people better than they do older people." Older people and their responsible relatives indicated some dissatisfaction with treatment received from doctors. This dissatisfaction may have resulted from experiences or, more likely, may simply have represented a stereotyped belief. About half of all older people and a smaller proportion of responsible individuals agreed with the statement that, "Doctors give you as much time and attention as you need, whether you're paying them or not."

160

Reports of Responsible

Individuals

Summary

The persons to whom the elderly would turn in a health crisis were intimately acquainted with the older people's health problems. These persons viewed the health status and needs of older people much as older people themselves did. Most of them believed that the older person they knew best was "well." While they knew the old person had many complaints and "aches and pains," they regarded these as usual and to be expected in later life. In most instances they considered the older person's health as good or better than the health of most people his age. Most of these close relatives and friends, like most older people themselves, felt that old people were seeing doctors as often as they should. Sometimes they deplored the tendency of the aged to treat themselves, but more often they accepted this behavior as part of older people's mode of life. Responsible individuals reported that the great majority of older people were paying routine medical bills from their own resources, and that at least two thirds of them recently hospitalized or experiencing serious illness had paid the attendant costs themselves. While only a small fraction of them thought their older relative was without medical or dental care because of lack of funds, they reported that as many as two older persons in every five would be unable to pay a medical bill as large as $500 without help from sons, daughters, other relatives, or charitable organizations.

161

VIII The Public Views the Needs of Older People What do American people think about the aged? At what age does the average American believe a man or woman is old? What does the public think about older people's health? Their finances? Where they should live? Does the public image of older people agree with the picture older people have of themselves? In November 1957 this survey interviewed a cross-section of the American public for their views about aging and older people. Since those interviewed ranged from 21 to well over 65 (the oldest were in their eighties), their personal experience with old age and the elderly differed greatly. Some had little personal knowledge of older people, while others had elderly parents or grandparents or were in the older age group themselves. When Is α Person O l d ?

Sixty-five has come to represent the legal beginning of old age in this country. At 65 both men and women may obtain full benefits under Social Security, as well as under many private pension plans. However, a substantial group of Americans believe that both men and women are old well before they reach 65. When asked, "At what age do you think a man or woman is old?" more than a third of the public cross-section said that men were old at some age before 65; almost half of the public thought that women were old earlier than 65 (Table 97). The younger the respondent the more likely he was to give a younger age. A forty-seven-year-old woman who thought that both men and women were old at seventy commented 162

The Public Views the Needs T A B L E 97. T h e age at which men and women are considered o l d — R e p l i e s of public cross-section c l a s s i f i e d by age of respondent Age at which men and women are considered old

Percentage distribution Respondents under 45

Total

Respondents 45 and over

Men Total

100.0

100.0

100.0

2.8 12.7 21.5 25.5 20.2 13.5 3.8

3.4 14.4 23.9 25.3 18.9 11.2 3.0

2.0 10.6 18.5 25.7 21.9 16.4 4.9

Total

100.0

100.0

100.0

Under 50 50-59 60-64 65-69 70-74 75 and over Don't know, depends Ν =

5.4 18.9 20.5 22.2 15.4 12.7 4.9 2,567

5.8 21.1 20.7 23.1 14.7 10.8 3.8 1,452

4.8 16.0 20.3 21.1 16.5 15.1 6.3 1,115

Under 50 50-59 60-64 65-69 70-74 75 and over Don't know, depends Women

on this when answering the question. "Of course." she said, "the older you get, the older the age gets." Age judgments were usually based on health criteria. The age at which people considered a person old was usually the age at which they thought a person's health problems became especially important. People associated the aging man with failing health and reduced physical vigor, rather than with retirement from work. They believed women became old at an earlier age than men, citing "physical changes" and "failing health" as the criteria of aging in women. The menopausal period was often noted as the time a woman became old. A forty-one-year-old woman said that a man was old at fifty because his health began to fail then. "Around that age they get aches and pains and have to slow down. Their resistance is lower at that time." She thought a woman was old at fifty because "after her menopause she can't do as much and requires more rest. You slow down and have to think about your health and be more cautious." A man of forty said that a man was old at sixty. He explained his

163

The Health of Older People answer: "If he has labored—take my class of people—he's pretty well worn out. He isn't fit for labor any more." He said a woman was old at fifty, however, "because her disposition and outlook on life changes. A woman fears growing old more than a man. Her health gets bad, she can't do the work she could when younger." A sixty-two-year-old man, who thought a man was old at seventy, thought a woman was old at sixty. He said, "By that time she is through bearing children and has the change of life. All things considered, she usually has health complications after that." A fifty-nine-year-old man, perhaps reflecting his own experience, said that a man became old between fifty-five and sixty because "they can't hold out to do a hard day's work and industry won't hire them." The belief that women become old earlier than men is widespread among the public. Retirement programs which permit women in comparable jobs to retire at earlier ages than men only reflect what "everybody knows to be true." In general, people believe that regardless of his calendar age a man is "young" or "middle-aged" as long as he is vigorous and active; they view a woman's age as more closely related to her calendar age. A man is as old as he feels; a woman as old as her birthdays. Health and Old Age

Americans generally have considerable first-hand knowledge about older people. The increased longevity of the American population is reflected in the large number of adults, some well into middle-age, who reported that they had living parents. Six of every ten persons interviewed had at least one living parent (Table 9 8 ) . Nine

T A B L E 98. respondent

P r o p o r t i o n of p u b l i c c r o s s - s e c t i o n w i t h l i v i n g p a r e n t s ,

P e r cent

by a g e of

of a l l persons

P e r c e n t of respon dents under 4 5

P e r c e n t of respondents 4 5 and over

A t least one l i v i n g parent

59.9

86.8

25.0

F a t h e r a n d mother both l i v i n g

33.0

53.5

6.4

6.4

8.2

4.0

20.5 2,567

25.1 1,452

14.6 1,115

S t a t u s of parent

Father only alive Mother only a l i v e

Ν=

164

The Public Views the Needs of every ten persons under 45 (although only about one of every four persons over 45) had at least one parent still alive. Because women live longer than men, more adult Americans have mothers living than fathers: 54 per cent reported having a mother living, 39 per cent a father still alive. People 45 and older are twice as likely to have a mother living than a father: one of every five had a mother still alive, while only one of every ten had a living father. Those members of the public who had living parents viewed their parents' health optimistically. Half thought that the health of their parent or parents was "good" (Table 99). People under 45 were more likely to say that their parents were in good health—an expected finding, since their parents were usually younger than the parents of persons over 45. The "sickest" group among surviving parents were the mothers of those people who were over 45 themselves. About one in three among these mothers was said to be in poor health. One in five of the surviving fathers of persons 45 and over was felt to be in poor health. American people generally accept the belief that most older people's health is "poor" or "fair." Although half of those with living parents thought their own parents' health was good, they and the reTABLE

99.

The

h e a l t h of a g e d p a r e n t s — E v a l u a t i o n of t h o s e i n p u b l i c c r o s s -

s e c t i o n w i t h l i v i n g p a r e n t s , c l a s s i f i e d b y a g e of r e s p o n d e n t Percentage distribution

Evaluation of health of father a n d mother

Respondents under 45 years

Respondents 45 years and over

H e a l t h of f a t h e r Total

100.0

100.0

100.0

Good

51.8

53.8

36.2

Fair Poor

34.0 11.6 2.7

33.3 10.4

39.7 20.7

2.6

3.4

(1.012)

(896)

(116)

100.0

100.0

100.0

48.9 3S.9

52.7 35.5

14.0 1.1

10.8 1.1

30.8 38.0 29.9 1.3

(1,375)

(1,141)

(234)

Not specified

Ν H e a l t h of mother Total Good Fair Poor Not specified

Ν

165

The Health of Older People mainder of the cross-section agreed that most older people were in only "fair" health (Table 100). It may be recalled that this same contrast between experience and belief appeared in the views of close relatives and friends of older people. The American public is generally aware of the ailments most common among older people. All persons interviewed were asked, "What sicknesses would you say are most usual among the older people you know?" The most usual answer to this question was cardiovascular disease, described as "heart trouble" or "high blood pressure." The second most usual answer was "arthritis." A forty-three-year-old woman whose parents, aged seventy-two and seventy-seven, were still living said that her parents were in good health. She thought that most older people, however, were only in fair health. Their most usual complaints, she said, were "rheumatism or arthritis or something like that . . . It's the strain from working hard." A forty-year-old woman said that her seventy-eight-year-old mother was in "good health, except she fractured her hip and can't get around." As for most other older people, she thought that by the time they reached sixty-eight they had "slowed down and have physical disabilities . . . heart trouble, arthritis . . . all those things seem to appear." A sixty-one-year-old woman said that most older people were in poor health because "so many people have heart attacks and are unable to work any more." She described the most common illnesses of the aged as "heart trouble, cancer, and arthritis." A sixty-three-yearold man, however, thought that most older people were in good

T A B L E 1 0 0 . T h e health of older people — E v a l u a t i o n of those in public crosssection" Percentage distribution Evaluation of health of older people

Total

Persons w i t h living parents or parents-in-law

Persons w i t h no living parents

Total

100.0

100.0

100.0

Good Fair Poor N o answer Ν =

35.2 51.1 12.5 1.2 2,567

36.5 51.9 10.8 0.9 1,821

31.8 49.3 16.4 2.5 746

° B a s e d on answers to the question: " I n general, how would you describe the health of most people you know who are 6 5 years or m a r e — w o u l d you say it was good, f a i r , or poor?"

166

The Public Views the Needs health. He, too, thought the most common illness of the aged was "heart trouble." The public cross-section apparently overestimated the proportion of older people who had health and hospital insurance coverage in 1957. Fifty-three per cent thought that most older people who had to be hospitalized met the costs of their hospital care through insurance payments (Table 101). Actually, only 45 per cent of all older people who had been hospitalized in 1956-57 reported that they had met the costs of hospitalization in whole or part through insurance payments. Usually, those who thought that most old people did not meet their hospital bills through prepaid insurance felt that older people should have health insurance. At the same time, they felt that circumstances beyond the control of old people kept them from purchasing health insurance—either that they could not afford health insurance premiums, or that insurance plans would not cover aged persons. Financial Responsibility for the A g e d

The public is divided in its views on financial responsibility for older people who cannot support themselves (Table 102). Only a small minority of Americans think that older people should take complete responsibility for financing their old age from their own resources—that is, from their savings and other assets. The majority T A B L E 1 0 1 · H o w d o older p e r s o n s u s u a l l y pay their h o s p i t a l b i l l s ? — A n s w e r s of t h o s e in p u b l i c c r o s s - s e c t i o n c l a s s i f i e d by a g e of r e s p o n d e n t 0 Percentage distribution M e t h o d of payment

Total

Respondents

Respondents

under 4 5

45 years

years

and over

Total

100.0

100.0

100.0

Older p e r s o n p a y s for h i m s e l f Insurance H e l p from c h i l d r e n F r e e care Don't know No answer

17.2 53.3 9.1 12.2 8.3 0.0 2,567

18.5 54.2 10.4 10.5 6.4 0.1 1,452

15.5 52.0 7.4 14.3 10.7 0.0 1,115

Ν=

° B a s e d o n a n s w e r s to the q u e s t i o n : " W h e n a n older p e r s o n around here (that y o u k n o w ) i s s i c k and h a s to g o t o the hospital, how do y o u s u p p o s e he p a y s for most of h i s b i l l — d o e s he pay for m o s t of it h i m s e l f , d o e s he h a v e i n s u r a n c e that p a y s for most of it, do h i s c h i l d r e n or other r e l a t i v e s pay for it, or d o e s he g e t free c a r e ?

167

The Health of Older People T A B L E 102. Who s h o u l d t a k e care of older p e o p l e when they are no longer w o r k i n g ? — A n s w e r s of all t h o s e in p u b l i c c r o s s - s e c t i o n " Percentage distribution Answer

Total S h o u l d p r o v i d e for themselves C h i l d r e n or r e l a t i v e s Employer pension plans Government through Social S e c u r i t y a n d other m e t h o d s Other a n d N o a n s w e r N =

Total

Person with l i v i n g parents or p a r e n t s - i n - l a w

P e r s o n s w i t h no l i v i n g parents

100.0

100.0

100.0

16.6 33.2 5.5

15.7 37.0 5.4

19.0 23.7 5.6

42.7 2.0 2,567

39.9 rlΦ $>>§ t>» β ft :

ä

S9

Ii is

Ii r

s\

d si fr

a ;

"

·

C sS 9 -P

3: s . 1: ί a a P.3 I

1

211

1Λ VO h· Χ

ϋ V

-Ρ Η

Si ϋί -ρ α g s i s

! S

fr

:

Η

ii n

x> a

Sal

s $ UDO i a . "

I S S S CO -Ρ Ή

216

s?§ a3 J£

41 I sa

si 8 fig OVO 3 o

ata

s s.

iMl-'i 3 4) "β JU -P a* *§ a -15 8 1 g R-ο ah s4»" Όa Η. e» j *ΐΡ • Ι ό ι Μ ; Ε ^uSät" ϊϊ8 SS U ü eβ gαo °' oJ4g. gL . ^ I s e ,5 sss 3 •&II jJ 41 Ο ü·Ο β sβs Ο

^ l ^ lΛft i fm R I ***** I i öß^eoas +3Μ ölΟ -Ρ Η «Tf -Ρ?»H3 •Η jgj ^ΗC«Ua Ckö« ^ t) -d4 «in s I j j 3ΛΛ

217

^c α « Qφ m

1 3a •Ρ Ό la

säl! efc£ "d ο is a l co +» ®

tt c aPi a Rl·3 "λ I «

al •rl £» ÜV ΌO ή Si

a 3η I ο i s " I I i

Λ -o un »Ii 3 1α 5 •ρ >» Η 4J fi «4»Η·Η3 3a Λ Η

OJ vo Ο Η LA 0\ w on ^

ö

Ii I| otK—* c

sis

sa

π a a π-e υaj υ οο

a1 sa Ό

*> &? c

•ρ to

5a »s

ϊ" £SP

•Η υΌ

in

Ii

US S5

κ 4)

+> J) Λ

ill

Iö ,s (£ U *ο

5§ Si

.(I »Χ»S Ιιι Q ί ~ -Η -Η•Ρ 4) -Ρ > -

(j ä Λ

7

£ * 5s

s j υI sSI

£S •5Β

3

|Ι ι

α ^ ^ •• 3

Is 18

C M C M OJ

* •ΒΡ Ό

a υ aο

8 d

s ε

la si

ta & * ^K Η ·Η Ο«— Siä g

V δ t"Ι α-β» 23 s CVI 3 * ffä 8

Ί!φ&α

g-

Iw l l sϋ £ 4j -μM

||1S ssSI

si

311

15 ι 4) §3 C Λ! :

ΪΙ s1*

^ss 3

S1

s

ail ih 1Ρ α& )3 Ό

ig

ϊ °

1 i 3ό if t> IS *• Ö Ό "Ö Κ Η ·Η Ή ω «a & & s.

S I

AG ii J:

1° Ii Ό -Ρ "i Ig

h

if

01 ο 4) · Η υ «d 5

SÄ ρ ο

S3

°

ν α

η

a • · · ο

ι! : : 1h jc ·· :» Ηr-lΆ Vi u • • 2S

a

41

«1 SS 31

§ sa

s•

ι:

•

u a -Η α • U

I« $- i -' ggal s · I ts & Ο. . 3 1 2 PS fc η « · ato Iο jml-16 »13! !ϊ 11 Iε är .•I II 3? ΗJ £ Si Is ii Is 5

218

ill

S3 " s •p «>

8 SI

η3 ss| $

«ι η Λ λ

ΗίΙ (Ί 4

;| Vi

ü s Od 1

S 1 3. α a | Λ h u

s $

1 *α «s Ά *> - $ S § V R * t £ I I s

δa '53r ο I β « η *

& οο « α>? a si s m

.

S « S ί S S

« i a s

Ü 1 s

8 I

8 £41 Ο

i s6

ν«* Ü δ

1 s

•Ρ β» Sa 3ν & ο β8

i =

Ι •d I

i

\

II

d

Η V >»Η ί ϊ S ϊ 3 . £ · Sa

3 Α"· ü i

.fis j ' S μ ff-p l i t

f ί>· 2 3j a·

111 »ga i h ο 1 ιΒ β » β ο !·3 VΒ hΛ . ·8 f | i

I i33 3 . 2s "a

I « I

I

β Λ 4 Ρ·

1

l

I '

ι f

V

1 s

*

ΐ U

219

Β I

• s f- 4> 4 Igt J» ja S 2 8s s, ! | L s s fj a · I j i ä • ä g l ί ajn έ ΐ ι I i i

220

221

•1

O O P S

•1

3

3

- 3 «

{

Ι Φ Μ ϊ m% ν

J

•ρ α "s η

i l s f j ;

υ

Φ t

Sit S

« I r a r

$

Ä ^ ^

S

§

Φ « ! " k •a

g ^ s s ^ S

g

^ 5 ^ 5 >-»

a

^

1 i l · i i ^ s i

! ^

o r g -

I

5

I

5

j f

1s

§

2

3

8 ü

S S

SS 33 " 1

φ 5 .3 3

iijjliii u l i l i i l

8

ί*

V w 4»

Ü Β

I

•SÜ

s .

is

Η £•8

t?

s

•s 3 α

* οι

t 3 II

a

iE 11 a s.t

Η

aυ n·Ρ Μ ο ί

s s .

ii

° Ρ

I

«Sä i d A S

I*

u S

ü l

-ö .

h

|U I

ο a» α

U

Π U U d o υ

55 ? ζ

k

S3 it

β Ο -6 w ί
-P

4J

^

ϊΐ

·Η

l·,

!l ιΐ

Ό

Ο

s i s ft

J

Λ

6

Si

111

11 II

8

a ω

£

S S

ο i

¥ «

α ί

Η Ά &

S

6

ο «

Ι^ Ι$ |